' 9. 


COL.  GEORGE  WASHINGTON  FLOWERS 
V^IORIAL  COLLECTION 


TRINITY  COLLEGE  LIBRARY 
DURHAM,  N.C. 


The  Gift  of 

Date_  37,  / J / 


■ 


M1 


A PBACTICAL  TEEATISE 


ON  THE  MOST  COMMON 


DISEASES  OE  THE  SOUTH: 


EXHIBITING 

THEIR  PECULIAR  NATURE, 

AND  THE 

CORRESPONDING  ADAPTATION  OF  TREATMENT. 

TO  WHICH  IS  ADDED 

AN  APPENDIX, 

CONTAINING  SOME  MISCELLANEOUS  MATTER. 

ALSO 

A GLOSSARY, 

EXPLAINING  THE  MEANING  OF  THE  TECHNICALITIES,  OR  MEDICAL 
PHRASES,  USED  IN  THIS  WORK. 


BY  THOMPSON  McGOWN,  M.D., 

GRADUATE  OF  TRANSYLVANIA  UNIVERSITY,  MEMBER  OF  THE  LEXINGTON  MEDICAL 
SOCIETY,  AND  A .PRACTITIONER  OF  THE  SOUTH. 


l;  Is  Ihere  no  balm  in  Gilead  ? is  there  no  physician  there  ?”  Why,  then,  may  not  all 
be  healed,  or  profiled? 


PHILADELPHIA: 

GRIGG,  ELLIOT  AND  CO., 

14  NORTH  FOURTH  STREET. 

1849. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1849,  by 
THOMPSON  Me  GOWN, 

in  the  Clerk's  Office  of  the  District  Court  for  the  Eastern  District  of  Pennsylvania. 


PHILADELPHIA  : 

T.  K.  AND  P.  G.  COLLINS,  PRINTERS. 


(d  I ( o 

M ) 


PREFACE. 


From  the  desire  that  has  very  frequently  been  ex- 
pressed by  many  of  the  best  southern  practitioners, 
and  also  from  my  own  practical  experience  and  ob- 
servation. I have,  for  some  time,  been  convinced  of 
the  great  necessity  that  existed  for  a medical  w'ork 
that  should  serve  as  a book  of  reference  and  instruc- 
tion in  relation  to  the  peculiarities  and  proper  treat- 
ment of  Southern  Diseases. 

Our  medical  books  having  been  written  almost 
entirely  by  European  and  northern  authors — how- 
ever useful  they  may  have  generally  been — are  not 
adapted,  as  experience  has  amply  proved,  to  the  dis- 
eases of  the  South.*  Impelled  by  these  considera- 
tions, I have  in  this  work  endeavored  to  supply,  in 
part,  this  desideratum.  The  book  has  not,  however, 
been  prepared  with  that  care  and  leisure  that  I could 
have  desired ; but,  nevertheless,  I have  endeavored 
to  express  myself  concisely  and  intelligibly  ; although, 
in  some  instances,  I have  intentionally  avoided  brevity, 
in  order  to  be  the  better  understood  by  the  general 
reader ; though,  by  this  course,  I may  have  violated 


* Dr.  Cartwright,  of  Natchez,  Mississippi,  says,  the  best  works  extant 
on  Diseases  of  the  South,  are  those  of  Hippocrates,  the  father  of  medicine. 


IV 


PREFACE. 


some  of  the  established  rules  of  composition.  Some 
errors  may  also  have  crept  into  the  work. 

In  connection  with  my  own  practical  experience 
and  observation,  I have  availed  myself  of  the  expe- 
rience of  some  of  the  most  erudite  southern  practi- 
tioners, most  of  whose  names  will  be  found  in  the 
work.  Reference  is  also  occasionally  made  to  foreign 
or  northern  authors,  in  instances  where  such  refer- 
ence is  pertinent. 

The  author  feels  confident  that  this  work  will  be 
of  great  value  to  students  of  medicine,  young,  and 
even  old  practitioners,  and  those  who  have  recently 
emigrated  to  the  south  or  southwest,  and  the  southern 
and  southwestern  people  generally. 

I believe  that  the  medical  as  well  as  the  legal  pro- 
fession is  in  error  in  using  technicalities , especially 
where  they  can  be  conveniently  avoided,  and  more 
particularly  in  practical  works,  in  which,  as  far  as 
possible,  they  should  be  supplanted  by  plain  English 
words,  in  order  that  all  persons  who  are  disposed  to 
inform  themselves,  to  some  extent,  on  the  subject  of 
medicine,  may  do  it  with  comparative  ease ; though 
it  should  be  recollected  that  technicalities  cannot  be 
entirely  dispensed  with,  at  least  at  present.  My 
experience  is,  that  nothing  human  is  more  certain 
than  that  the  more  the  public  are  instructed  in  eclec- 
tic or  philosophic  medicine,  the  better  are  they  pre- 
pared to  appreciate  it;  they  thus  learn  the  import- 
ance of  obtaining  the  services  of  a qualified  physician, 
in  case  they  or  their  families  or  friends  should  be  so 
unfortunate  as  to  be  afflicted  to  a degree  which  their 


PREFACE. 


V 


own  knowledge  is  not  competent  to  control ; and  they 
are  also  thus  rendered  more  competent  to  judge  of  the 
qualifications  of  a practitioner,  and  not  so  easily  im- 
posed on  by  mountebanks,  or  by  every  new  or  fool- 
ish notion  that  is  gotten  up  to  gull  the  public  for  a 
time,  from  mere  pecuniary  considerations.  It  ap- 
pears, on  the  one  hand,  that  the  human  mind  has  a 
great  proclivity  to  deal  in  that  in  which  it  can  see 
some  reason  or  plausibility,  or  which  it  pretty  well 
comprehends;  or,  on  the  other,  that,  in  relation  to 
which  it  is  totally  ignorant,  and  for  which  it  can 
perceive  no  reason,  but  which,  nevertheless,  com- 
mands its  superstitious  credulity.  Hence,  from  re- 
mote ages  to  the  present  day,  charms  and  ceremonies 
— which  common  sense  teaches  us  can  have  no  in- 
fluence, except  on  or  through  the  mind — have  been 
used  for  the  cure  of  diseases.  In  the  onward  and 
upward  march  of  the  human  mind,  as  intelligence 
becomes  more  general,  we  may  hope,  at  least  in  a 
great  measure,  to  see  these  superstitious  notions  ban- 
ished from  the  world.  In  order,  then,  that  the  regu- 
lar practice^  that  eclectic  or  philosophic  medicine — the 
principal  foundation  of  which  appears  to  have  been 
laid  between  twenty-two  and  twenty-three  hundred 
years  ago,  by  Hippocrates,  who  is  commonly  called 
“ The  Father  of  Medicine” — should  be  properly  ap- 
preciated or  confided  in  by  the  public,  every  disci- 
ple of  Esculapius,  every  member  of  the  regular  pro- 
fession, should  take  an  interest  in  attracting  the 
public  more  to  the  subject  of  rational  medicine,  and 
communicate  information  as  opportunity  may  offer. 


VI 


PREFACE. 


The  author  has,  therefore,  in  order  that  the  public 
may  be  benefited,  as  well  as  his  professional  brethren, 
endeavored  to  adapt  his  composition  to  the  general 
reader.  Having  been  compelled,  however,  to  use 
some  technicalities,  a glossary  is  added  to  explain 
their  meaning.  There  is  one  objection  to  instruct- 
ing some  non-professional  persons  on  the  subject  of 
medicine,  and  this  is,  that  they  become  bigoted,  and 
profess  to  know  as  much  as  physicians,  and  are  there- 
by emboldened  to  practice,  at  the  risk  of  the  patient’s 
life,  when  a physician  should  be  called  in. 

It  is  somewhat  remarkable  that  so  little  attention 
is  paid  in  our  common  schools  and  academies  to  the 
outlines  of  anatomy,  physiology,  and  the  general  prin- 
ciples of  medicine.  It  is  not  expected  that  all  per- 
sons will  be  learned  in  medicine,  but  surely  these 
subjects  are  of  such  importance  to  every  one,  that 
they  should  not  be  so  ignorant  of  them.  Of  late 
years,  I believe,  there  seems  to  be  more  interest  felt 
in  this  matter,  and,  ere  long,  we  may  hope  to  see  it 
more  extensively  introduced  into  the  schools  of  gene- 
ral literature. 

I had  thought  of  writing  an  introductory  chapter 
to  this  work,  on  the  General  Principles  of  Medicine, 
having  some  original  peculiar  views,  which  I consi- 
der founded  in  the  laws  of  truth,  and  which,  when 
understood,  enable  us  to  reconcile  apparent  incon- 
sistencies, and  various  opinions  of  eminent  medical 
men,  and  are  also  well  calculated,  to  a considerable 
extent,  to  prevent  physicians  from  being  led  into 
error  by  the  sophistry  of  their  imaginations,  and 


PREFACE. 


vii 

which  also  greatly  simplify  the  subject  of  medicine, 
so  that  an  intelligent  public  may,  in  a great  measure, 
comprehend  it,  and  perceive  its  rationality.  But  as 
a proper  delineation  of  this  subject  wmuld  require  a 
volume  (which  I have  not  had  time  to  prepare),  I 
have  omitted  it,  having  endeavored  to  teach  prin- 
ciples as  well  as  practice  in  this  work  ; and  if  it  is 
sufficiently  patronized  and  the  author  encouraged,  he 
may,  in  the  future,  provided  opportunity  permits, 
prepare  a work  on  the  general  principles  of  medicine, 
and  perhaps,  also,  a more  comprehensive  edition  of 
this  wrork. 

In  the  following  pages,  I have  endeavored  to  be 
guided  by  the  light  of  truth ; and  though  I may  have 
freely  alluded  to  the  errors  of  some  of  my  profession- 
al brethren,  it  is  not  because  I love  them  less,  but 
that  I love  truth  and  humanity  more : and,  as  has 
been  said  by  some  writer,  though  I should  cast  mis- 
siles at  the  spots  on  the  sun,  it  is  no  evidence  that  I 
despise  the  brightness  of  its  disc. 

Hoping  and  believing  that  my  professional  bre- 
thren, and  the  public,  may  be  amply  rewarded  by 
carefully  consulting  this  work,  it  is  most  respectfully 
submitted  to  them. 

THOMPSON  Me  GOWN,  M.D. 
August,  1849. 


TESTIMONIALS. 


Philadelphia,  Penn.,  July,  1849. 

Whilst  this  work  was  passing  through  the  press,  I received  a letter  from 
a friend  in  the  South,  who  advised  me  to  have  testimonials,  in  order  that 
those  with  whom  I am  not  acquainted  may  he  assured  of  the  merits  of  this 
book,  and  therefore  seek  an  early  opportunity  to  obtain  it.  This  I had  not 
thought  of  doing,  expecting  it  to  make  its  way  on  its  own  merits,  if  it  has 
any ; it  is  clear,  however,  that  these  cannot  be  appreciated  till  the  work  is 
perused.  And,  therefore,  not  having  prepared  myself  with  testimonials 
for  this  purpose,  and  it  now  being  too  late — as  the  work  will  soon  be  out  of 
press — in  deference  to  the  suggestion  of  my  friend,  I will  here  insert  some 
communications  (which  I happen  to  have  in  my  trunk)  that  were  handed  to 
me  on  other  occasions  and  for  other  purposes ; and  I hope  the  gentlemen 
whose  names  appear  below  will  excuse  me  for  this  liberty. 


The  following  were  kindly  handed  to  me,  when  I was  about  leaving  Mis- 
sissippi to  locate  in  North  Alabama. 

Hillsboro’,  Scott  County,  Mississippi,  July  19 th,  1848. 

To  all  whom  it  may  concern. 

The  undersigned  having  learned  that  their  highly  respected  friend,  T. 
McGown,  51.  D.,  is  going  to  leave  this  place,  and  as  he  may  locate  where 
he  is  not  known,  we  voluntarily  take  great  pleasure  in  recommending  him 
as  a gentleman  of  moral  habits,  probity,  mild  and  courteous,  worthy  of  the 
confidence  and  esteem  of  all  those  who  respect  morality,  virtue,  and  honesty, 
lie  located  here  in  1844,  and  has  proven  himself  to  be  a talented  and  skill- 
ful physician;  he  has  practiced  in  all  our  families,  and  we  have  been  highly 
pleased  with  his  success.  He  is  a pleasant  and  agreeable  friend,  and  we 
very  much  regret  his  leaving  here,  and  hope  that,  wherever  he  may  locate, 
his  merits  may  be  duly  appreciated.  * * * * 

■J.  51.  Chambers,  Minister  of  the 
Gospel  in  the  Baptist  Church. 

J.  J.  Smith,  Esq. 

J.  -J.  Chambers,  Ex-clerk,  Circuit 
Court  of  Scott  County,  Miss. 


X 


TESTIMONIALS. 


From  Rev.  J.  I).  Abney. 

Carthage,  Miss.,  May  2 9th,  1848. 

Elder  J.  M.  Chambers,  Hillsboro’,  Miss. 

Dear  brother  in  the  Lord:  I am  now  on  my  way  home  from  my  appoint- 
ment in  Madison  County.  * * * * * * I did  intend  to  call  at 

Hillsboro’,  in  order  to  spend  some  time  with  our  friend  Dr.  McGown  pre- 
vious to  his  leaving,  but  my  business  presses  me  on  home  by  the  shortest 
route.  Give  the  doctor  my  best  wishes  ********* 
My  acquaintance  with  the  doctor  has  been  truly  intimate  and  of  the  most 
pleasant  character,  and  I hope  you  will  have  the  goodness  to  hand  him 
this;  and  I hope  that  his  modesty  will  not  prevent  him  from  using  it  on 
any  proper  occasion ; for  I can,  with  the  greatest  pleasure,  say  to  the  afflicted, 
that  he  is  a man  who  stands  pre-eminently  high  as  a knowing  and  attentive 
physician ; and  to  the  good  citizens  of  any  community,  I can,  with  plea- 
sure say,  that  he  is,  as  his  deportment  fully  shows  him  to  be,  a faithful 
friend  and  gentleman ; and  I earnestly  hope  that  he  may  find  a situation 
that  will  be  able  to  appreciate  his  high  attainments,  and  his  moral  worth. 

I am  yours  in  love, 

J.  D.  Abney. 


Hillsboro’,  Mississippi,  July  20 th,  1848. 


Gentlemen: — 

This  will  introduce  you  to  Dr.  Thompson  McGown.  ***** 
I have  enjoyed  the  pleasure  of  an  intimate  acquaintance  with  Dr.  McGown 
for  near  three  years,  and  I take  pleasure  in  saying,  that  his  exemplary 
conduct  as  a gentleman,  and  his  success  as  a practitioner,  have  made  him 
more  friends,  wrought  a confidence  in  his  abilities,  and  gained  him  a repu- 
tation that  is  seldom  the  fortune  of  one  of  his  age  to  attain. 

I risk  nothing  in  saying,  that  you  only  have  to  become  acquainted  with 
Dr.  McGown,  to  admire  him  as  a gentleman,  and  appreciate  his  abilities 
as  a physician. 


Respectfully, 


I).  R.  -Jones,  Sheriff  of 
Scott  County,  Miss. 


Hillsboro’,  Miss.,  July  14 th,  1848. 

To  all  whom  it  may  concern. 

Some  four  years  since,  I became  acquainted  with  Thompson  McGown. 
M.  D.,  at  this  place;  during  the  past  three  years  it  has  been  my  pleasure  to 
cultivate  with  him  an  intimate  and  sociable  intercourse,  both  in  private 
and  professional  life ; occasionally  requiring  his  professional  attention  as  a 
pdiysician. 


TESTIMONIALS. 


XI 


In  my  intercourse  with  him,  which  has  been  of  the  most  intimate  cha- 
racter, I have  found  him  to  possess  those  rare  qualities  so  necessary  to  the 
character  of  a gentleman.  ****** 

His  professional  ability  in  this  vicinity  has  been  thoroughly  tested  in 
numerous  cases,  nearly  all  of  whom  now  live  to  award  him  the  just  meed 
of  praise,  which  well-directed  skill,  timely  administered,  claims  from  the 
hands  of  a grateful  circle  of  friends. 

E.  Rush  Bucknor,  Attorney  at  Late, 
Hillsboro’,  Miss. 


The  three  following  brief  extracts  are  from  the  undersigned,  to  gentlemen 
whose  names  appear,  the  letters  never  yet  having  been  handed  to  them. 

Neshoba  County,  Miss.,  April  15th,  1849. 

•J.  B.  Kirtland,  Esq.,  Memphis,  Tennessee. 

Dear  Sir: — 

Please  permit  me  to  introduce  to  your  acquaintance  my  friend  Dr. 
McGown,  who  visits  your  town  for  the  purpose  of  locating  * . * * The 
Dr.  has  for  some  time  past  been  engaged  in  preparing  a medical  work  for 
publication.  I take  great  pleasure  in  saying  to  you,  that  the  Dr.  is  a gen- 
tleman of  high  standing,  both  as  a citizen  and  a practitioner  of  medicine, 
*•■***■* 

Yours  Respectfully, 

H.  M.  Walsh. 

The  other  two  extracts  I thought  of  making,  are  in  substance  as  the 
above ; one  of  them  addressed  to  Dr.  Lard  of  Tippah  County,  Miss.,  and 
the  other  to  Messrs.  Wisdom  & Walsh,  Purdy,  Tenn. 


Erasmus  S.  Broyles,  M.  D.,  of  Aberdeen,  Miss.,  in  a letter  to  me  under 
date  of  April  19th,  1849,  after  learning  that  I was  about  to  publish  this 
work,  says:  “It  will  afford  me  pleasure  to  patronize  your  work  when  it 
makes  its  advent  to  this  place." 

The  Editor  of  the  Southern  Patriot,  a newspaper  published  at  Athens, 
Alabama,  after  examining  a portion  of  the  manuscript  of  the  work,  gave  it 
a highly  complimentary  notice  in  his  paper. 

In  conclusion,  I will  remark,  that  a number  of  physicians,  and  others, 
have  already  subscribed  or  spoken  for  a copy  of  the  work  in  advance,  in 
anticipation  of  its  publication. 


' ; 


TABLE  OF  CONTENTS. 


Malarious  Diseases 

PAGE 

CHAPTER  I. 

9 

CHAPTER  II. 

Intermittent  Fever — Chills  and  Fever  . . . . .30 


Cachexia 

CHAPTER  III. 

80 

CHAPTER  IV. 

Tuberculous  Cachexia — Consumption,  &c.  . . . .94 


Scrofula — Rickets 
Chronic  Rheumatism 

CHAPTER  V. 

.139 
. 140 

Tabes  Mesenterica 

CHAPTER  VI. 

143 

Chronic  Bronchitis 

CHAPTER  VII. 

ib. 

CHAPTER  VIII. 

Haemoptysis,  or  Spitting  of  Blood  .....  147 
Hydro-polyaemia,  or  Serous  Polyaemia — Treatment  . . . 150 


Dropsy — Treatment  of  . 

CHAPTER  IX. 

ib. 

CHAPTER  X. 

Enlargement  of  the  Spleen  and  Splenic  Cachexia  . . . 152 


XIV 


CONTENTS. 


PAGE 

CHAPTER  XI. 

Liver — Chronic  Enlargement  and  Induration  of  155 

, CHAPTER  XII. 

Nervous  Diseases — Epilepsy — Puerperal  Convulsions  . . 156 


CHAPTER  XIII. 


Atonic  Dyspepsia 

CHAPTER  XIV. 

. 162 

Leucorrhcea,  or  Whites  . 

. . . 

. 165 

Chronic  Metritis 

CHAPTER  XV. 

. 171 

Bysmenorrhoea.  or  Painful  Menstruation 

CHAPTER  XVI. 

. 173 

Additional  articles  for  the 

cure  of  Intermittent  Fever 
CHAPTER  XVII. 

. 176 

Congestive  Fever,  or  Cong 

estive  Chills 
CHAPTER  XVIII. 

. 180 

Remittent  Fever 

. 

. 224 

Jaundice 

CHAPTER  XIX. 

. 293 

Fellow  Fever 

CHAPTER  XX. 

. 294 

Acute  Rheumatism 

CHAPTER  XXI. 

. 306 

Typhoid  Pneumonia 

CHAPTER  XXII 

. 308 

Diarrhoea  and  Dysentery 

CHAPTER  XXIII. 

* 

. 326 

Asiatic  Cholera  . 

CHAPTER  XXIV. 

. 353 

Croup  (cynanche  trachealis), 

. '383 

CONTENTS.  XV 

APPENDIX. 

PAGE 

I. 

Clap,  or  Gonorrhoea  ......  399 

II. 

Miscellaneous  ........  407 

Concussion,  Jar,  or  Fall  ......  407 

III. 

Incised  wounds  ........  408 

Lacerated  and  contused  wounds  .....  409 

Gun  Cotton  ........  410 

Collodion 410,  412 

IY. 

Worms  in  the  Alimentary  Canal  . . . . . 413 

Y. 

Catarrh,  or  cold  . . . . . . . . 416 

VI. 

Ephemeral  Fever  .......  418 

VII. 

Itch  (scabies),  ........  420 


GLOSSARY .421 

INDEX 439 


A PRACTICAL  TREATISE 


ON 

DISEASES  OF  THE  SOUTH. 


CHAPTER  I. 

MALARIOUS*  DISEASES. 

The  almost  universal  malarious  influence  in  the 
southern  and  western  portions  of  the  United  States,  as 
well  as  many  other  portions  of  the  globe,  undoubtedly 
renders  this  subject  one  of  the  most  interesting  which 
pertains  to  the  practice  of  medicine.  This  is  a subject 
which  does  not  only  interest  physicians,  but  all  those 
who  reside  in  those  portions  of  the  world  where  this 
malarious  influence  is  felt. 

A committee  (Prof.  Bartlett  being  one  of  the  number) 
appointed  by  the  Lexington  Medical  Society  in  1847,  re- 
marked: “ Extensively  as  malarious  fever  has  been  written 
about,  there  are  many  points  of  its  natural  history  wdiich 
need  further  elucidation.  Amongst  these  may  be  men- 
tioned, particularly,  the  following : the  comparative 
liability  of  the  sexes,  of  the  black  and  white  races,  and 
of  different  periods  of  life,  to  the  several  forms  of  the 
disease ; the  influence  of  race  upon  its  severity  and  dan- 
ger ; the  relative  proportions,  in  different  years  and  locali- 

* I use  this  term  for  the  sake  of  convenience,  and  to  he  understood,  with- 
out assuming  to  prove  or  disprove  the  existence  of  such  a thing  as  malaria , 
or  miasm , according  to  what  is  generally  understood  by  these  terms. 

2 


10 


MALARIOUS  DISEASES. 


ties,  of  the  three  principal  forms — intermittent,  remittent, 
and  congestive ; the  most  common  type  of  the  pure  in- 
termittent form ; and  the  variations  in  the  general  cha- 
racter of  the  disease,  in  different  seasons.” 

A southern  and  malarious  region  having  been  the  place 
of  my  nativity,  and  having  had  considerable  practical 
experience  in  the  various  forms  of  disease  produced  or 
modified  by  malarious  influence ; and,  moreover,  having 
taken  pains  to  acquire  what  information  I could  on  the 
subject,  from  southern  practitioners  and  others,  and  from 
books  and  medical  journals,  I am  induced  to  believe  that 
the  condensation  of  this  summary  may  convey  to  those 
who  feel  interested  enough  to  read  this  work,  some 
information  that  may  not  be  without  interest  and  profit, 
especially  to  those  who  expect  to  practice  in  the  South  or 
West;  and  I am  the  more  inclined  to  prepare  it,  from 
not  only  observing  the  improper  and  deleterious  practice 
of  many  physicians  who  have  been  educated  at  the 
North,  but  from  the  common  observation  of  many  of 
my  professional  brethren  of  the  South,  and  also  by  many 
of  the  non-professional.  Indeed,  it  is  remarked  by  many  of 
the  older  practitioners  of  this  country,  who  came  here  from 
the  North,  that  they,  and  others  who  had  been  educated 
at  the  North,  and  subsequently  located  in  the  South,  had 
to  learn  to  treat  the  diseases  of  this  country  after  they 
came  here.  I feel  assured  that  very  few,  if  any,  of  the 
northern  teachers  and  writers  sufficiently  appreciate  the 
peculiarities  of  not  only  the  malarious  fevers,  but  of  many 
other  forms  of  disease  which  are  modified  by  this  climate 
and  locality,  and  requiring  a corresponding  adaptation  of 
treatment.  It  gives  me  pleasure,  however,  to  observe 
that  some  of  the  teachers  at  the  North  are  not  so  fully 
obnoxious  to  these  remarks  at  present,  as  heretofore.  It 
appears  that  some  of  them,  at  least,  are  taking  more  pains 
than  formerly,  to  make  themselves  acquainted  with  the 


MALARIOUS  DISEASES. 


11 


diseases  of  the  South;  and  I am  the  more  gratified  at 
this  increased  manifestation  of  interest,  because  I believe 
the  abuses  in  practice  in  the  South  will  be  but  tardily 
ameliorated  till  the  northern  professors  and  writers  are 
prepared  to  give  students  from  the  South  the  requisite 
and  proper  instructions  in  these  respects; — as  from  other 
advantages,  the  competency  of  northern  teachers  in  other 
respects,  and  the  reputation  of  northern  schools,  a great 
many  students  in  the  South  will  perhaps  continue  to  go 
to  the  North  to  acquire  medical  information.  A large 
number  of  southern  physicians  are  still  too  much  inclined 
to  look  at  the  diseases  of  this  country  through  northern 
spectacles.  I would  that  the  observation  of  the  late  Dr. 
Eberle  was  more  universally  true,  that  “ The  American 
practitioner,  free  from  the  trammels  of  systems,  and  the 
dogmas  of  the  schools,  pays  no  further  regard  to  the 
verba  magistri  than  is  sanctioned  by  his  own  experience 
and  observations.  He  inquires,  observes,  and  reflects  for 
himself,  and  adopts  the  mode  of  treatment  which  he 
finds,  from  varied  experience,  most  successful.  A prac- 
tice, which  has  received  the  approbation  of  a numerous 
portion  of  the  profession,  may  be  confidently  regarded  as 
founded  on  individual  experience  and  observation,  and 
not  adopted  on  mere  authority,  and  entitled,  therefore,  to 
full  confidence.”  As  regards  southern  diseases,  these 
remarks  apply  appropriately  to  many  southern  practi- 
tioners, especially  the  better  informed  ones,  on  the  subject 
of  southern  diseases.  Ere  long,  I hope  to  see  northern 
teachers,  as  well  as  southern  ones,  and  medical  writers 
generally,  pay  more  attention  to  this  subject ; as  I feel 
well  assured  that  the  profession  would  be  amply  rewarded 
for  such  attention,  bj?  additional  trophies  in  the  healing 
art,  as  well  by  removing  some  of  the  opprobria  from  an 
honorable  and  useful  profession,  and  one  which  is  essen- 
tially necessary,  not  only  in  relieving  the  sufferings  and 


12 


MALARIOUS  DISEASES. 


diseases  of  the  human  family,  but  as  a guardian,  in  point- 
ing out  the  principles  of  hygiene,  and  those  means  of 
prophylaxis  which  are  best  calculated  to  secure  health 
and  comfort,  and  immunity  from  disease.  But  as  it  is 
human  nature  to  be  tenacious  of  preconceived  opinions, 
time  will  be  required  to  eradicate  error,  and  bring  about 
a great  desideratum,  a correct  and  general  knowledge  of 
the  diseases  of  the  South,  and  the  principles  of  treatment 
theij  demand.  I have  not  the  presumption  to  suppose 
that  I can  remove  the  veil,  and  at  once  appreciate  the 
nature  of  all  these  diseases,  but,  being  willing  to  contri- 
bute according  to  my  experience  and  ability,  I hope  to 
receive  the  approbation  of  my  professional  brethren, 
especially  of  the  South,  in  this  humble, — but  I trust, 
laudable  undertaking. 

It  is  not  my  intention  to  enter  into  an  analytical  ex- 
amination of  the  different  opinions  as  to  the  existence  or 
non-existence  of  what  is  termed  “ miasm  f “ marsh 
poison ,”  “ malaria ,”  etc.  The  Italian  term  malaria, 
which  merely  means  “ had  air,”  is  not  that  signification 
which  is  commonly  attached  to  the  word.  Those  who 
believe  in  the  existence  of  such  a poison,  are  of  the 
opinion  that  it  is  sui  generis,  and  produces  its  peculiar 
influence  on  the  system,  which  differs  from  everything 
else.  There  are  others  who  do  not  acknowledge  the 
existence  of  this  hypothetical  poison,  but  believe  that  the 
morbid  influences  attributed  to  it  are  produced  by  varia- 
tions of  temperature,  heat  and  moisture,  etc.  etc. 

A retrospective  view  of  the  history  and  prevalence  of 
the  different  forms  of  malarious  disease  in  different  locali- 
ties, would  be  a task  impossible,  and  if  possible  almost 
ad  infinitum,  and  without  equivalent  profit  arising  from 
such  a prolix  historical  detail.  Yet  it  may  not  be  with- 
out interest  to  notice  briefly  some  of  the  times  and  places 
of  its  prevalence  in  our  own  country.  Dr.  Cartwright, 


MALARIOUS  DISEASES. 


13 


of  Natchez,  Mississippi,  is  of  opinion  that  the  different 
forms  of  malarious  disease  were  better  known  bj  Hippo- 
crates, than  any  of  the  medical  profession  of  the  present 
day.  I may  premise  that  its  prevalence  in  any  year  or 
place,  seems  to  be  induced  by  occult  causes — which,  as 
yet,  we  have  been  unable  to  appreciate.  In  some  places, 
where  it  is  endemic,  a certain  season  may  be  wet  and 
healthy,  or  dry  and  healthy.  The  late  Hr.  Eberle  ob- 
served : “ It  would  seem  that  either  the  generation  of 
miasmata,  or  their  power  of  producing  intermitting  and 
remitting  fevers,  is  greatly  controlled  by  certain  occult 
conditions,  wholly  unconnected  with  any  appreciable 
circumstances,  with  regard  to  atmospheric  temperature, 
or  any  of  the  other  known  requisites  for  the  production 
of  this  poison and  further,  correctly  remarks  : “ In  cer- 
tain districts  of  the  temperate  latitudes,  malarious  fevers 
will  sometimes  disappear,  or  become  extremely  rare  for 
a number  of  successive  years,  and  then  gradually  become 
more  and  more  common,  until,  in  the  course  of  a few 
seasons,  they  assume  the  prevalence  of  an  epidemic:  and 
yet  no  material  difference  will  be  obvious  between  these 
periods  of  exemption  from,  and  prevalence  of  disease,  in 
relation  to  what  are  deemed  the  necessary  concomitants 
for  the  production  of  miasmata.”  Professor  Dunglison 
says : “ It  is  proper  to  remark,  that  such  a change  occa- 
sionally occurs  in  a malarious  region,  as  to  render  it 
entirely  healthy,  and  this  without  our  being  able  to  assign 
any  plausible  conjecture  for  the  alteration.  At  times,  too, 
after  having  left  one  of  its  former  haunts,  the  malaria 
may  return,  after  the  lapse  of  a longer  or  shorter  period.” 
The  correctness  of  these  remarks  is  corroborated  by  the 
observation  of  all  those  who  have  for  many  years  noticed 
its  prevalence.  Professor  Dunglison  further  observes  : 
“Not  many  years  ago,  the  villas  on  the  banks  of  the 
Delaware  were  almost  uninhabitable  in  the  latter  part  of 


14 


MALARIOUS  DISEASES. 


summer,  and  in  the  autumnal  months,  but  they  are  now 
healthy,  whilst  those  on  the  verdant  and  sylvan  banks  of 
the  Schuylkill  suffer  from  malarious  emanations;”  and 
further  remarks,  that  “ It  is  met  with  in  all  climates,  but 
less  perniciously,  perhaps,*  in  the  colder  regions  of  the 
globe,  than  in  the  torrid  or  the  temperate.  In  the  same 
region,  too,  it  prevails  more  virulently  in  some  districts 
than  in  others the  cause  of  it  “ sometimes  exhibiting 
itself  in  the  high  grounds,  whilst  the  low  are  exempt; 
and  occasionally  visiting  tracts  of  country  where  it  had 
previously  been  unknown  ; whilst,  on  the  other  hand,  it 
may  leave  localities  where  it  had  been  before  an  annual 
visitor.”  Dr.  Boling,  of  Montgomery,  Alabama,  says : 
“ The  exact  combination  of  circumstances  under  which 
that  mysterious  agent  of  disease,  malaria,  is  generated, 
remains  yet  to  be  satisfactorily  explained,  as  well  as  the 
chemical  and  physical  properties  belonging  to  it.  We 
find  at  times  all  the  circumstances  in  existence,  so  far  as 
we  are  capable  of  understanding  or  appreciating  them, 
which  on  a previous  occasion  had  been  supposed  to  cause 
its  development,  without  the  presence  of  malarious  dis- 
ease ; and  again,  we  find  such  diseases  prevailing  to  a 
considerable  extent,  when  of  the  generally  recognized 
causes  of  malaria,  but  few  are  present,  or,  if  all,  their 
existence  in  but  a feeble  degree.” 

In  certain  portions  or  localities  in  the  southern  and 
western  States,  where  it  is  more  or  less  common  every 
year  in  the  latter  part  of  the  summer,  and  during  autumn, 
and  not  unfrequently  to  a less  extent  during  the  entire 
year,  it  appears  as  an  endemico-epidemic  in  the  latter 

* Prof.  D.  might  properly  have' left  out  the  word  “perhaps,”  and  also  re- 
marked that  it  does  not  prevail  equally  iu  all  regions  of  the  globe.  W hile 
it  is  almost  unknown  or  uncommon  in  the  New  England  States  (according 
to  Prof.  Bartlett),  where  typhoid  fever  mostly  prevails,  it  is  the  most  com- 
mon form  of  disease  in  the  south-western  portion  of  this  Union. 


MALARIOUS  DISEASES. 


15 


part  of  summer  and  in  autumn,  at  which  times  it  is  apt  to 
be  more  severe ; sometimes  assuming  what  has  been 
termed  the  pernicious  remittent  type,  and  at  others  the 
form  of  congestive  chill.  It  is  said  that  in  1822,  a bad 
form  of  bilious  remittent  fever  prevailed  at  Louisville. 
I believe  it  was  about  the  year  1824  or  ’5,  when  a very 
fatal  form  of  fever  prevailed  about  Huntsville,  Ala.  The 
usual  mode  of  treatment  was  of  so  little  avail,  that  Dr. 
Thomas  Fearn  was  induced  to  try  large  doses  of  quinine, 
which  proved  successful ; and  it  appears  that  he  is  the 
first  who  used  large  doses  of  this  article,  a practice  which 
has  since  become  very  popular  in  the  southern  and 
western  States,  amongst  the  most  enlightened  and  suc- 
cessful practitioners.  Malarious  disease  prevailed  in  some 
portions  of  North  Alabama,  in  the  summer  and  autumn 
of  1827  and  ’8;  especially  in  the  region  about  Decatur, 
Moulton,  Courtland,  and  Tuscumbia.  Dr.  Hogg  gives 
an  account  of  the  epidemic  fevers  of  Natchez,  Miss.,  in 
1837,  ’8,  and  ’9  ; and  takes  brief  notice  of  the  malignant 
double  tertian.  Dr.  T.  D.  Bell  gives  an  account  of  an 
epidemic  congestive  fever,  attended  with  dysentery, 
which  prevailed  in  the  flat,  low,  marshy  country  near 
the  junction  of  the  Black  Warrior  and  Tombigbee  rivers, 
in  Alabama,  in  the  summer  of  1829.  Malarious  fever 
also  prevailed  in  many  places  in  the  South,  in  1839  and 
’40,  and  with  a good  deal  of  intensity  or  severity.  In 
the  latter  part  of  summer  and  in  autumn,  in  1840,  it 
appeared  as  an  epidemic  in  ibhe  counties  of  Franklin. 
Coffee,  Warren,  and  others  in  Middle  Tennessee;  the 
severer  forms  being  very  common ; and  prevailed  to  a 
considerable  extent  in  the  same  region,  and  elsewhere,  in 
1842.  In  the  same  season  of  the  year,  in  1844,  it  pre- 
vailed in  the  southern  part  of  Alabama  and  Mississippi, 
manifesting  its  severer  forms  in  those  endemic  localities 
where  it  had  formerly  more  virulently  prevailed,  the 


16 


MALARIOUS  DISEASES. 


healthier  localities  mostly  furnishing  the  milder  forms, 
with  perhaps  some  exceptions.  Dr.  Charles  McCormick, 
Assistant  Surgeon,  U.  S.  Army,  made  a report  at  Fort 
Gamble,  Florida,  Sept.  1841,  of  167  cases  of  fever;  119 
being  of  the  quotidian  type,  32  of  the  tertian,  and  16  of 
the  remittent  form.  Two  or  three  cases  assumed  the 
congestive  form,  and  he  remarks:  “I  think  the  strongest 
peculiarity  of  character  these  cases  have  presented,  this 
season,  has  been  the  strong  tendency  they  have  had  to 
run  into  and  assume  the  remittent  type.  In  fact,  in  many 
of  the  cases,  it  has  been  extremely  difficult  to  draw  a 
distinct  and  plain  line  of  demarkation,  to  say  where  the 
one  ended  and  the  other  commenced.” 

Dr.  Lewis,  of  Mobile,  Ala.,  observes,  when  speaking 
of  what  he  calls  the  third  epoch  in  the  Medical  History 
of  Alabama:  “But  in  1834,  we  find  its  approach  (i.  e. 
fever)  was  insidious  and  unobserved,  giving  no  serious 
warning  of  its  proximity,  until  the  unconscious  victim 
was  secure  in  its  grasp.  The  patient  first  complained  of 
depression,  heat  and  burning , when  to  the  touch  the  sur- 
face was  icy  cold.  That  cold,  that  first  stage,  is  now  the 
stage  of  disease  and  peril;  and  that  reaction,  which  in 
past  days  was  looked  to  with  fear  and  trembling,  would 
now  be  hailed  as  the  messenger  of  returning  health  and 
vigor.” 

Malarious  fever  appeared  as  an  epidemic  in  the  region 
of  country  about  Nashville,  Tennessee,  in  1845.  A 
writer  to  the  editor  of  the  New  Orleans  Medical  Journal, 
under  date  of  Nov.  6th,  1845,  says  : “ Since  I wrote  you 
last,  we  have  been  dreadfully  scourged  with  disease. 
Although  our  town  has  been  healthful  as  usual,  the 
surrounding  counties  of  Middle  Tennessee,  and  the  ad- 
jacent counties  of  Kentucky,  have  suffered  more  from 
sickness  than  the  ‘ oldest  citizen’  can  remember  at  any 
former  period.  The  disease  has  been  principally  fever, 


MALARIOUS  FEVERS— PREVALENCE. 


17 


and  of  the  ordinary  remittent  and  intermittent  types,  re- 
quiring, as  far  as  I have  observed  and  inquired,  no 
important  modification  in  the  treatment.  The  disease 
commenced  about  the  middle  of  September,  and  con- 
tinued with  unabated  violence  until  about  the  25th  of 
October,  when  it  ceased  with  the  approach  of  cool  wea- 
ther, and  very  suddenly.  I have  not  been  able  to  ascer- 
tain that  one  locality  has  been  more  liable  to  its  ra- 
vages than  another ; the  high,  hilly,  and  even  mountain- 
ous districts,  as  well  as  the  flat,  rich  country,  have  been 
alike  sufferers.  And  during  its  severest  form,  the  country 
was  perfectly  dry,  not  having  had  rain  for  many  months.” 
The  summer  season  at  Woodville,  Miss.,  1846,  was 
wTet,  and  fevers  were  mostly  of  the  tertian  type.  Ther- 
mometer from  73°  to  93°.  The  congestive  fever  appeared 
as  an  epidemic  at  Pensacola,  in  1844,  for  the  first  time, 
and  again  in  the  summer  and  autumn  of  1846.  Dr.  T. 
A.  Cooke,  of  Opelousas,  Louisiana,  says,  according  to 
his  experience,  which  is  confirmed  by  others  who  have 
enjoyed  a better  opportunity  than  himself  for  observation, 
that  congestive  fever  does  not  bear  to  our  autumnal 
bilious  fevers  a ratio  greater  than  two  per  cent.  During 
eleven  years’  practice  in  Opelousas  and  the  adjacent 
country,  he  had  not  observed  on  an  average  more  than 
twelve  cases  a year.  At  Montgomery,  Ala.,  in  1845,  it 
was  dry  and  very  healthy ; in  1846,  wet  and  healthy. 
The  sickly  season  at  Columbus,  Miss.,  is  mostly  confined 
to  August,  September,  and  October ; but  in  1846,  marked 
cases  of  bilious  fever  commenced  early  in  July;  and 
though  this  sickly  season  was  long,  the  diseases  were 
mostly  mild,  and  of  the  remittent  and  intermittent  form, 
till  about  the  middle  of  September  they  became  more 
obstinate ; and  there  were  a few  cases  of  congestive  fever. 
The  summer  was  very  wet.  In  the  latter  part  of  Sep- 
tember, the  worm  or  caterpillar  committed  great  depre- 


18 


MALARIOUS  FEVERS— PREVALENCE. 


dations  on  the  cotton,  every  leaf  in  the  largest  farms  was 
eaten  up  ; and  the  effluvia  from  the  cotton  field  was  sick- 
ening, and  almost  intolerable.  Dr.  J.  B.  Wilkinson,  of 
Louisiana  (New  Orleans  Medical  Journal , July  1845), 
says  : “ In  the  last  three  years,  during  the  spring,  sum- 
mer, and  autumn,  I have  treated  successfully  between  six 
and  seven  hundred  cases  of  intermittent  fever,  embracing 
every  variety  of  form,  from  the  simplest  grade  to  those 
cases  where  complete  stupor  and  insensibility  were  co-ex- 
istent,  and  succeeded  to  the  cold  stage,  and  those  cases 
in  which  the  paroxysm  was  ushered  in  by  symptoms  and 
appearances  so  similar  to  those  indicative  of  cholera  mor- 
bus, that,  unless  acquainted  with  the  history  of  the  case, 
an  observer  wmuld  have  declared  them  cases  of  the  latter 
disease.”  These  cases,  perhaps,  should  more  properly 
be  considered  as  the  dysenteric  variety  of  congestive  fever. 

John  Dawson,  M.  D.,  of  Jamestown,  Ohio,  in  1846, 
says  : “ The  summer  and  autumnal  diseases  were  more 
prevalent,  so  far  as  my  own  experience  was  concerned, 
than  last  season,  although  that  was  generally  regarded  as 
being  a sickly  season  compared  with  several  of  the  pre- 
ceding. All  parts  of  the  State,  if  I have  been  correctly 
informed,  have  not  been  equally  affected.  Our  towns, 
as  a general  rule,  have  been  comparatively  healthy, 
while  certain  country  situations  have  suffered  beyond 
any  former  precedent.  Nor  have  I been  able  to  trace 
any  connection  between  the  occurrence  of  certain  of  our 
autumnal  diseases  and  particular  districts  of  country. 
Along  the  courses  of  the  larger  streams  of  water,  the  dis- 
eases considered  peculiar  to  such  localities  have  not  been 
more  frequent,  or  more  severe,  than  in  the  vicinity  of 
small  streams,  or  even  in  the  interior.”  He  further  re- 
marks : “ Bilious  remittent  and  intermittent  have  had  an 
almost  unexampled  prevalence.”  The  bilious  form  pre- 
vailed some  in  August,  more  in  September,  and  he  thinks 


MALARIOUS  FEVERS— PREVALENCE. 


19 


obtained  its  greatest  prevalence  in  October.  The  cases 
in  August  and  September  were  generally  of  short  du- 
ration, and  easily  controlled  with  purgatives  and  qui- 
nine. I believe  the  severer  forms  of  malarious  fever 
prevailed  as  an  endemico-epidemic  in  some  portions  of 
North  Mississippi,  in  the  summer  and  autumn  of  1842, 
and  again  in  1843;  and  I believe  in  the  same  seasons, 
and  with  considerable  malignity,  in  the  south-western 
portion  of  Alabama. 

It  is  said  there  is  more  sickness  at  Tuscumbia,  Ala., 
this  season — autumn  of  1848 — than  has  been  for  many 
years.  The  different  forms  of  malarious  disease,  as  is  usual 
in  this  valley,  were  the  forms  of  disease  that  prevailed ; 
some  of  fatal  congestive  form.  I may  here  remark,  that  in 
the  Tennessee  river  valley,  and  more  particularly  on  the 
south  side,  from  Gunter’s  Landing  in  North  Alabama,  to 
Tuscumbia,  including  Decatur  and  Courtland,  there  is 
more  or  less  of  the  three  principal  forms  of  malarious 
fever  every  summer  and  autumn ; and,  indeed,  some  have 
ague  and  fever  all  winter.  Previous  to  the  10th  of  Sep- 
tember, the  quotidian  is,  perhaps,  the  most  common  form ; 
after  this,  it  is  apt  to  assume  more  or  less  the  tertian, 
double  tertian,  irregular,  remittent,  or  what  some  call  the 
continued  form, — perhaps  improperly, — and  an  occa- 
sional case  of  the  congestive  form. 

Perhaps  I have  already  been  more  tedious  than  neces- 
sary in  noticing  the  prevalence  of  malarious  fever  in  dif- 
ferent localities,  and  at  different  times.  This  part  of  the 
subject  might  be  extended  to  almost  an  indefinite  length, 
as  before  remarked,  without  corresponding  practical  ad- 
vantage. I will  close  this  part  of  the  subject,  therefore, 
by  a few  tabular  statements  and  remarks. 

Fever  Statistics,  showing  the  relative  proportion  of  the 
different  forms  of  malarious  and  other  fevers  admitted 
into  the  New  Orleans  Charity  Hospital,  during  a period 


20 


MALARIOUS  FEVERS— PREVALENCE 


of  seven  years,  from  1st  January,  1841,  to  1st  January, 
1848,  inclusive ; monthly  and  annually.  Reported  by 
E.  D.  Fenner,  M.  D.  Dr.  F.  says:  “This  institution 
is  probably  the  most  extensive  fever  hospital  in  the  world, 
and  affords  the  greatest  facilities  for  investigating  the 
disease  in  all  its  forms  and  varieties.” 


1841. 

FEVERS. 

>— 5 

Feb’y. 

March. 

April. 

May. 

June. 

July. 

| August. 

Q. 

O 

Vj 

| October. 
| Nov. 

Dec. 

r3 

© 

Intermittent,  - - 

3 

27 

45 

39 

28 

65 

187 

151 

18 

66  93 

72 

794 

Typhoid, 

1 

5 

6 

12 

Congestive, 

4 

3 

i 

7 

3 

3 1 

2 

24 

Remittent,  - 

3 

2 

2 

9 

6 

31 

31 

5 

1 7 

2 

39 

Malignant  Intermittent 

3 

3 

6 

Yellow,  ... 

174 

642 

252  37 

8 

1113 

Bilious, 

| 

3 

11 

32 

46 

41 

37 

71 

22S 

362 

665 

322  143 

93 

1991 

Total  admissionof  all  diseases,  4380. 


1842. 

FEVERS. 

January. 

Feb’y. 

March. 

April. 

May. 

June. 

| July. 

j August. 

| Sept 

j October. 

| Nov. 

Dec. 

Total. 

Intermittent, 

45 

29 

35 

39 

45 

124 

160 

169 

144 

140 

110 

61 

1092 

Remittent, 

4 

1 

3 

4 

8 

12 

34 

41 

35 

11 

3 

155 

Typhoid,  - 

9 

2 

4 

2 

2 

2 

1 

22 

Bilious,  - 

2 

3 

9 

3 

1 

o 

o 

1 

23 

Congestive, 

1 

3 

3 

2 

10 

5 

4 

9 

2 

1 

40 

Gastric, 

1 

2 

6 

1 

1 

11 

Catarrhal,  ... 

1 

1 

1 

3 

Yellow, 

47 

247 

93 

23 

410 

Nervous,  - - i ' - 

1 

1 

Adynamic, 

1 

1 

59 

31 

39 

47 

52 

142 

197 

259 

439  2S4 

150 

79 

175S 

Total  admissions  of  all  diseases,  4404. 


1843. 

FEVERS. 

January. 

Feb’y. 

March. 

April. 

>-> 

§ 

June. 

| August. 

© 

cz> 

October. 

| Nov. 

Dec. 

Total. 

Intermittent, 

31 

30 

35 

31 

19 

40 

70 

9S 

12S 

136 

149 

76 

843 

Typhoid, 

2 

2 

4 

Remittent, 

1 

1 

9 

40 

75 

49 

12 

8 

10 

205 

Catarrhal, 

1 

1 

2 

Bilious,  - 

1 

1 

15 

3 

37 

5 

2 

2 

3 

2 

71 

Typhus, 

3 

6 

9 

Congestive, 

3 

17 

4 

24 

Gastric, 

1 

1 

1 

4 

7 

Continued, 

1 

1 

Yellow, 

23 

1SS 

365 

351 

111 

15 

1053 

Cephalic, 

3 

36 

30 

35 

33 

34 

60 

194 

372 

544 

501  273 

107 

2222 

Total  admissions  of  all  diseases,  5013. 


MALARIOUS  FEVERS — PREVALENCE, 


21 


1844. 

FEVERS. 

January. 

Feb’y. 

March. 

April. 

May. 

June. 

=3 

| August. 

| Sept. 

| October. 

> 

o 

£ 

| Dec. 

Total. 

Intermittent, 

66 

49 

41 

32 

44 

75 

176 

258 

255 

261 

216 

116 

1589 

Remittent, 

2 

4 

2 

1 

4 

24 

30 

47 

67 

55 

5 

3 

244 

Yellow,  ... 

2 

2 

1 

1 

1 

68 

52 

25 

152 

Typhoid, 

6 

1 

3 

3 

10 

12 

11 

8 

6 

20 

80 

Simple,  - 

3 

6 

3 

12 

Gastric,  - 

1 

2 

1 

5 

2 

11 

Typhus,  ... 

4 

4 

Bilious,  - 

2 

4 

2 

1 

3 

1 

13 

Inflammatory,  - 

1 

2 

2 

2 

2 

2 

11 

Congestive,  - 

1 

7 

11 

17 

14 

13 

15 

3 

81 

Adynamic, 

2 

2 

4 

Continued, 

2 

3 

5 

Eruptive,  - 

1 

i 

21 

84 

63 

62 

106 

151 

201 

151 

339 

241 

206 

148 

2207 

Total  admissions  of  all  diseases,  6136. 


1845. 

FEVERS. 

January. 

Feb’y. 

March. 

April. 

May. 

June. 

| August. 

G. 

<D 

CO 

October. 

> 

O 

£ 

Dec. 

Total. 

Intermittent, 

7 

75 

57 

44 

79 

112 

145 

96 

279 

196 

189 

124 

1403 

Typhoid, 

7 

6 

5 

2 

10 

8 

11 

14 

IS 

20 

15 

23 

139 

Remittent, 

2 

1 

1 

11 

17 

00 

00 

34 

33 

17 

154 

Congestive,  - 

3 

1 

1 

2 

1 

4 

5 

4 

21 

Inflammatory,  - 

2 

1 

1 

4 

Yellow, 

1 

1 

Continued, 

1 

2 

1 

1 

5 

Nervous, 

1 

1 

1 

* 

3 

Bilious,  . - 

1 

2 

6 

1 

1 

1 

14 

Simple,  - 

1 

4 

1 

1 

1 

2 

9 

Pernicious, 

2 

2 

1 

4 

Ephemeral,  - 

1 

1 

Adynamic, 

1 

1 

2 

Scarlet, 

2 

2 

Catarrhal,  - 

1 

i 

21 

84 

63 

52 

106 

151 

201 

151 

339 

241 

206 

148J1763 

Total  admissions  of  all  diseases,  6136. 


1846. 

FEVERS. 

January. 

Feb’y. 

March. 

April. 

May. 

June. 

July. 

| August. 

Q, 

O 

October. 

Nov. 

Dec. 

Total. 

Intermittent, 

79 

58 

75 

76 

85 

138 

214 

227 

359 

376 

310 

SI 

2078 

Typhoid, 

30 

13 

7 

5 

10 

12 

14 

17 

5 

7 

23 

52 

195 

Typhus,  - 

Remittent, 

3 

3 

5 

7 

6 

2 

9 

22 

36 

7 

3 

103 

Congestive, 

1 

1 

2 

4 

2 

5 

9 

2 

5 

31 

Yellow, 

29 

83 

32 

4 

148 

Bilious,  ... 

1 

1 

2 

4 

Pernicious  Intermittent, 

6 

4 

1 

11 

Adynamic, 

Scarlet,  ... 

2 

o 

1 

2 

1 

8 

Catarrhal, 

1 

1 

Nervous, 

1 

1 

1 

3 

Malignant, 

2 

2 

Larvata, 

2 

2 

1 

1 

6 

Pernicious, 

2 

9 

11 

Gastro-Hepatic, 

1 

1 

Ataxic,  - 

1 

1 

117 

75 

90 

83 

104 

161 

246 

255 

433 

522 

380 

147 

2603 

Total  admissions  of  all  diseases,  S044. 


22 


MALARIOUS  FEVERS— PREVALENCE. 


1847. 

FEVERS. 

January. 

Feb’y. 

March. 

April. 

May. 

June. 

July. 

August. 

Sept. 

October. 

Nov. 

Dec. 

Total. 

Intermittent, 

144 

117 

98 

153 

140 

211 

223 

74 

53 

00 

380 

341 

2192 

Typhoid, 

40 

21 

50 

73 

66 

20 

7 

2 

1 

6 

60 

111 

457 

Typhus,  - 

2 

4 

107 

165 

369 

57 

1 

4 

100 

236 

1045 

Remittent, 

4 

1 

4 

9 

17 

38 

69 

64 

25 

12 

18 

8 

269 

Congestive, 

1 

1 

1 

2 

3 

12 

10 

1 

1 

2 

2 

36 

Yellow, 

5 

148 

1611 

777 

219 

49 

2 

2811 

Bilious, 

2 

2 

4 

7 

2 

1 

9 

7 

8 

42 

Pern.  Intermittent, 

1 

2 

1 

1 

5 

Adynamic, 

1 

1 

Ephemeral,  - 

3 

2 

1 

6 

12 

Catarrhal, 

1 

4 

18 

23 

Inflammatory, 

1 

5 

Continued, 

1 

2 

3 

193 

142  157 

346 

396 

661 

521 

1756 

' 857 

512 

622  834 

6901 

Total  admissions  of  all  diseases,  11,890. 


In  justice  to  Dr.  Fenner,  it  should  be  observed,  that 
he  has  given  the  names  of  fevers  as  he  found  them  on 
the  books  of  the  hospital,  without  attempting  to  rectify 
the  “ very  faulty  nomenclature  applied  to  fevers,”  parti- 
cularly in  the  city  of  New  Orleans. 

From  the  above  “ tables,  it  appears  there  were  admit- 
ted, of  all  kinds  of  fever,  19,445  cases — of  which  999  L 
were  marked  1 Intermittent'  Add  to  which  26  marked 
£ Pernicious''  and  1 Malignant  Intermittent ,’  and  257  mark- 
ed ‘ Congestive1  (which  is  only  the  American  cognomen 
for  the  same  form  of  Intermittent  fever),  and  you  will 
have  10,274  Intermittents,  or  more  than  one-half  of  the 
whole  amount , by  1103. 

“ Is  it  not  curious  to  note  the  gradual  increase  and 
decline  of  intermittent  fever  at  this  hospital  ? And  also 
the  remarkable  fact  that  this  form  of  fever  is  never  en- 
tirely absent,  not  even  at  the  zenith  of  the  worst  epidemics 
of  the  yellow  fever?  In  August,  1847,  when  there  were 
admitted  1611  cases  of  yellow  fever,  there  were  also  ad- 
mitted 74  cases  of  intermittent.  But  examine  the  statis- 
tics carefully,  and  you  will  discover  other  curious  facts, 
which  I shall  not  take  the  time  to  point  out. 

“ The  following  table  will  show  the  relative  preva- 


MALARIOUS  FEVERS— PREVALENCE. 


23 


lence  of  what  is  marked  ‘ Intermittent  fever ’ at  the  differ- 
ent seasons  of  the  same  seven  years  : — 


Spring. 

Summer. 

Autumn. 

'Winter. 

1841 

112 

403 

177 

92 

1842 

119 

453 

394 

135 

1843 

85 

208 

413 

137 

1844 

117 

469 

732 

231 

1845 

180 

353 

664 

206 

1846 

236 

569 

1045 

218 

1847 

391 

508 

691 

602 

Totals. 

1240 

2963 

4116 

1621 

“Two  interesting  questions  may  here  be  examined, 
viz.,  What  proportion  of  all  this  intermittent  fever  really 
originated  in  New  Orleans , and  in  what  part  of  the  city 
did  most  of  it  occur  ? 

“ The  city  of  New  Orleans  is  certainly  a great  tho- 
roughfare, and  has  a larger  transient  or  floating  popula- 
tion, perhaps,  than  any  other  to  be  found.  It  is  accessible 
by  ships,  steamboats,  and  land  carriage.  It  is  surrounded 
by  a low,  level,  and  very  fertile  country,  having  a large 
number  of  free  white  laborers.  This  class  in  the  country 
is  engaged  principally  in  draining  wet  land,  and,  to  some 
extent,  in  the  mechanic  arts;  about  the  city,  it  is  also 
extensively  engaged  in  draining  the  suburbs;  but,  per- 
haps, to  a greater  extent  in  street  labor,  such  as  paving, 
draying,  and  loading  and  unloading  ships  and  steamboats 
on  the  levee.  Their  residences  are  chiefly  in  the  newer 
and  more  retired  parts  of  the  city,  where  rents  are 
cheapest;  but  they  are  generally  interspersed  among 
those  of  the  wealthier  class. 

“ Now,  the  Charity  Hospital  is  opened  gratuitously  to 
all  indigent  persons,  male  and  female,  white  or  colored, 
who  may  wish  to  enter,  and  there  is  no  obstacle  to  ad- 
mission. This  charity  is  only  offered  to  the  indigent, 
but  pay  wards  are  provided  for  those  who  are  able  to 
afford  a moderate  compensation. 


24 


MALARIOUS  FEVERS— PREVALENCE. 


“ I believe  it  has  been  established,  that  the  poorer 
classes  suffer  more  than  any  others  from  all  kinds  of 
fevers.  Such  is  certainly  the  fact  here,  where  the  usual 
exciting  causes , such  as  intemperance  in  eating  and 
drinking,  and  exposure  to  the  hot  sun,  etc.,  are  very 
potent.  The  records  of  the  Charity  Hospital  do  not 
afford  any  precise  information  as  to  the  length  of  resi- 
dence in  New  Orleans.  The  question  is  asked,  and  the 
time  stated ; but  the  clerk  informed  me  that  he  made  no 
distinction  between  a residence  in  the  city  proper  and 
the  neighboring  country.  The  house  surgeon,  and  one 
of  the  clerks,  both  gave  the  opinion  that  most  of  the  cases 
of  intermittent  fever  occurred  amongst  the  laborers  in 
the  suburbs  and  vicinity  of  the  city.  But  the  truth  is, 
the  laborers  on  the  levee,  streets,  and  canals,  furnish  the 
greatest  number  of  cases  of  all  kinds  of  fever  at  this  place. 
My  own  opinion  is,  that  those  localities,  within  the  pre- 
cincts of  the  city,  which  afford  the  greatest  amount  of 
intermittent  fever,  also  afford  the  greatest  amount  of  re- 
mittent, bilious,  and  yellow  fevers;  moreover,  that  they 
are  all  dosehj  allied  affections. 

“ If  I wrere  asked  what  sort  of  index  these  hospital 
statistics  afford  as  to  the  prevalent  fevers  among  the  better 
classes  of  society  in  this  city,  I might  be  at  a loss  for  a 
satisfactory  reply.  I think  that  the  people  in  good  cir- 
cumstances, who  live  wrell  (as  they  generally  do),  and  are 
not  imprudent,  suffer  but  little  from  fever  in  this  city. 
Those  who  have  but  recently  settled  here,  are  apt  to  take 
yellow  fever,  when  it  prevails;  but,  as  they  generally  have 
prompt  attendance,  the  mortality  amongst  them  is  small, 
and  many  escape  it  entirely.  They  appear  to  suffer  more 
from  the  eruptive  fevers  than  any  others.  No  one,  aware 
of  the  stupid  imprudence  and  negligence  of  the  laboring 
classes,  can  be  surprised  at  the  mortality  amongst  them. 


MALARIOUS  FEVERS— PREVALENCE. 


25 


They  receive  high  wages  for  their  labor,  and,  having  no 
idea  of  economy,  it  too  often  causes  their  ruin. 

“ One  more  reference  to  the  statistics,  and.  I have  done. 
It  appears  that  the  total  admissions  of  all  diseases  into 
the  main  building  of  the  Charity  Hospital,  during  the 
above-stated  period  of  seven  years,  was  45,713,  of  which 
19,445  were  for  fevers,  and  of  these  last,  10,274  were  for 
the  different  forms  of  intermittent  fever .” 

From  9th  August  to  10th  October,  1847,  the  following 
cases  are  reported  at  Montgomery,  Ala.:  Fever,  Inter- 
mittent, Simple,  319;  Remittent,  Simple,  141 ; Remit- 
tent, Pernicious,  10;  Remittent,  Infantile,  11;  Ty- 
phoid, 2. 

At  Woodvilie,  Miss.,  occurring  in  the  practice  of  three 
physicians,  from  15th  August  to  14th  October,  1847  : 
Fever,  Intermittent,  38 ; Remittent,  45  ; Remittent,  In- 
fantile, 25 — One  fatal ; Continued  Bilious,  6 ; Congestive, 
9 — one  fatal. 

I have  been  informed  by  a respectable  citizen  (Mr. 
Davis)  of  Decatur,  Ala.,  that,  in  1840,  there  were  57 
families  in  towm,  and  in  the  sicklv  season  there  wTas  sick- 
ness  in  52  of  them,  in  12  of  which  all  wrere  sick,  both 
black  and  white.  It  was  also  very  sickly  at  this  place, 
and  in  the  surrounding  country,  in  the  summer  and 
autumn  of  1836,  with  considerable  fatality;  one  work- 
man made  74  coffins.  At  this  place,  in  the  autumn  of 
1848, 1 noted  39  cases  of  Quotidian  Intermittent ; 8 Ter- 
tian; 8 Double  Tertian;  2 Quartan;  13  Irregular, 
mostly  inclined  to  the  Quotidian  type ; and  a few  cases 
of  the  Remittent  and  Congestive  forms. 

This  summary  has,  perhaps,  been  already  sufficiently 
extended.  From  this  review  it  appears  that  the  inter- 
mittent is  by  far  the  most  common  form  of  malarious 
fever.  From  extensive  inquiries,  and  from  my  own  ob- 
servation, the  quotidian  is  the  most  common  type  of  in- 
3 


26 


MALARIOUS  FEVERS— COMPARATIVE  LIABILITY. 


termittent  fever.  In  some  unhealthy  localities,  some 
believe  the  tertian  to  be  the  most  common  type.  The 
tertian  generally  being  a severer  and  more  obstinate  form, 
and,  therefore,  more  frequently  requiring  medical  aid, 
may  explain  the  reason  why  authors  have  been  led  to 
suppose  it  is  the  most  common. 

M.  Nepple  has  endeavored  to  determine  under  what 
circumstances  intermittent  fevers  may  manifest  a quoti- 
dian, tertian,  or  quartan  type.  It  would  appear  that  the 
relative  frequency  of  these  types  varies  with  the  latitude. 
Out  of  3,114  cases  of  fever  treated  at  Bona  and  Algiers, 
and  out  of  954  cases  treated  in  the  canton  of  Marthiel 
(Ain),  the  types  were  as  follows  : — 


All  medical  writers,  who  have  written  on  fever  as  it 
exists  in  northern  climates,  agree  in  regarding  the  tertian 
as  the  most  common  type,  while  the  above  facts  prove 
that  the  quotidian  is  more  frequent  in  warmer  latitudes. 
The  quotidian  type,  according  to  M.  Nepple,  occurs  most 
frequently  in  warm  years,  wThile  the  tertian  form  is,  on 
the  other  hand,  most  frequent  in  cold  years ; the  quoti- 
dian type  also  appearing  to  be  less  dependent  on  marsh 
miasmata  than  on  accessory  circumstances.* 

Comparative  Liability,  &c. — In  addition  to  my  own 
observation  and  experience,  I have  made  considerable 
inquiries  in  relation  to  the  “ comparative  liability  of  the 
sexes,  of  the  black  and  white  races,  and  of  different 
periods  of  life,  to  the  several  forms  of  the  disease ; the 
influence  of  race  upon  its  severity  and  danger.” 

1st.  As  to  the  liability  of  the  sexes,  perhaps  males 


Bona  and  Algiers. 


Ain,  France. 
443 
420 
91 


Quotidian  fevers 

Tertian 

Quartan 


- 2,181 
901 


32 


* See  London  Med.  Gaz.,  Sept.  1846,  or  Med.  News,  Dec.  1846. 


MALARIOUS  FEVERS— COMPARATIVE  LIABILITY. 


27 


are  somewhat  more  frequently  the  subjects  of  the  several 
forms  of  malarious  disease,  than  females  ; but  it  appears 
that  the  difference  is  very  little ; and  under  the  same  cir- 
cumstances there  is  perhaps  no  difference,  one  being  just 
as  liable  to  it  as  the  other. 

2d.  As  regards  the  comparative  liability  of  the  black 
and  wlrite  races  to  the  several  forms  of  the  disease,  I be- 
lieve I can  confidently  state,  that  when  both  are  placed 
under  the  same  circumstances,  there  is  no  difference ; 
nor  does  there  appear,  under  the  same  circumstances, 
any  difference  as  to  its  severity  or  danger.  Those  who 
have  resided  for  some  time  in  a malarious  district,  appear 
to  be  less  liable  to  it,  and  its  severity  less  with  them, 
than  those  who  have  recently  arrived  from  a healthy  re- 
gion of  country;  hence,  the  citizens  of  Charleston,  South 
Carolina,  on  visiting  their  rice  plantations  in  the  coun- 
try, are  more  obnoxious  to  it  than  the  work  hands  who 
remain  on  the  plantations.  It  is  also  disposed  to  be  much 
more  virulent  under  these  circumstances.  Dr.  Dickson, 
formerly  of  Charleston,  now  of  New  York,  says:  “In 

the  bills  of  mortality  for  the  city  of  Charleston,  you  will 
find  every  year  a certain  number  of  cases  distinguished 
by  the  appellation  of  ‘country  fever.’  The  phrase  is 
employed  to  denote  the  febrile  attack,  which  follows 
within  a short  time,  and  with  appalling  certainty,  an  ex- 
posure to  the  concentrated  malaria  of  the  low  country  in 
our  immediate  vicinity.  To  sleep  a single  night  upon 
his  plantation,  involves  the  southern  agriculturist  in  the 
most  serious  danger;  nay,  he  is  not  safe  if  he  indulge 
himself  in  frequent  visits,  even  by  day,  to  his  rice  fields, 
or  inhale  too  often,  under  any  circumstances,  the  pesti- 
lential air  of  our  swamps  and  marshes.”  It  is  proper  to 
remark  that  the  slaves  which  reside  on  these  plantations 
are  by  no  means  exempt  from  malarious  disease,  but  the 
law  above  referred  to  appears  to  hold  good  here,  as  else- 


28 


MALARIOUS  FEVERS— COMPARATIVE  LIABILITY. 


where,  viz. : that  those  who  have  resided  for  some  time 
in  a malarious  district  are  less  liable  to  it,  and  its  seve- 
rity less  with  them,  than  those  who  have  recently  arrived 
from  a healthy  region  of  country.  I have  been  informed 
that  the  negroes  use  “ bitters'1''  pretty  freely,  on  these  rice 
plantations,  as  a prophylaxis.  The  planters  in  Alabama. 
Tennessee,  Mississippi,  Louisiana,  Arkansas,  and  else- 
where, who  reside  on  their  plantations,  together  with 
their  families,  appear  to  be  no  more  liable  to  the  several 
forms  of  malarious  disease  than  the  negroes ; but,  in  some 
seasons  and  localities,  the  negroes  appear  to  suffer  most 
(perhaps  on  account  of  their  greater  exposure),  especially 
from  what  is  termed  typhoid  pneumonia , in  the  southern 
and  western  States,  which  seems  to  be  caused  and  modi- 
fied by  malaria , cold  and  humidity,  and  exposure.  This 
form  of  disease  appears  to  be  more  common  and  fatal 
amongst  the  black  population  than  the  white,  especially 
where  the  latter  are  not  exposed  in  out-door  business ; and 
I believe  it  is  rather  more  common  among  the  black  males 
than  the  black  females,  where  the  latter  remain  mostly 
within  doors,  while  the  former  are  exposed  to  the  vicis- 
situdes of  weather,  especially  wet  weather,  in  the  latter 
part  of  the  winter,  and  during  the  spring  months;  for  it 
is  at  these  times  that  this  form  of  disease  mostly  prevails. 
I would  not  wish  to  be  understood  that  the  white  popu- 
lation are  exempt  from  it ; nay,  in  certain  unhealthy  loca- 
lities it  sometimes  prevails  with  great  malignity  amongst 
them.  A great  many,  both  black  and  white,  suffered, 
and  many  died  of  it,  in  Decatur,  Ala.,  and  vicinity,  in 
the  latter  part  of  the  winter  and  spring  in  1846 ; and 
again  during  the  same  season  in  1847.  I believe  it  is 
generally  more  malignant  early  in  the  spring  than  at 
any  other  time ; — but  I will  defer  the  further  considera- 
tion of  this  subject  till  I come  specially  to  treat  of  it. 

3d.  As  to  the  comparative  liability  of  the  different  pe- 


MALARIOUS  FEVERS— COMPARATIVE  LIABILITY. 


29 


riods  of  life  to  the  several  forms  of  malarious  disease,  it 
appears  that  those  between  the  ages  of  two  years  and 
fifty  or  sixty,  are  most  liable  to  intermittent  fever.  I be- 
lieve that  those  who  are  over  sixty  years  of  age  are  some- 
what less  liable  to  it  than  those  under  two  years.  The 
susceptibility  of  those  under  two  years  appears  to  in- 
crease with  increase  of  age.  And  here  I will  take  occa- 
sion to  remark  that  young  children  are  more  frequently 
the  subjects  of  intermittent  fever,  than  is  supposed  by 
many.  I have  frequently  known  them  laboring  under 
this  form  of  disease  when  it  was  not  suspected  by  their 
parents,  who  supposed  their  child  was  very  sick  with 
some  other  malady,  or  they  did  not  conjecture  what  was 
the  matter.  I have  also  known  practitioners  to  overlook 
or  mistake  its  character.  Of  this  I shall  have  more  to 
say  when  I come  to  speak  particularly  of  intermittent 
fever. 

Children  under  five  years  of  age  are  less  liable  to  re- 
mittent fever  than  those  who  have  passed  this  age.  Those 
between  two  and  five  years  of  age  appear  to  be  more 
liable  to  it  than  those  under  two  years,  but  it  does  not 
appear  to  occur  very  frequently  in  the  former.  Those 
under  two  years  of  age,  so  far  as  I am  aware,  are  seldom  the 
subjects  of  remittent  fever,  though  they  are  not  entirely 
exempt  from  it.  Professor  Geddings,  of  Charleston,  in 
1822,  speaks  of  an  infant  that  died  of  autumnal  fever, 
which  Professor  Dunglison  notices  under  the  head  of 
Malignant  Remittent  Fever. 

It  appears  that  a very  large  majority  of  the  cases  of 
congestive  fever  occur  among  adults,  or  those  who  have 
arrived  at  the  age  of  puberty ; though  it  is  not  exclusively 
confined  to  them;  as  children  of  three  years,  or  five  years 
and  upwards,  are  sometimes  the  subjects  of  it.  In  the 
autumn  of  1848,  I saw  a case  in  an  infant  about  two 
and  a half  months  old. 

Poverty  and  destitution,  want  of  sufficient  and  whole- 


30 


INTERMITTENT  FEVER— CAUSES' OF. 


some  nourishment,  exposure  and  intemperance,  undoubt- 
edly largely  contribute  to  render  all  ages,  sexes,  or  races, 
much  more  obnoxious  to  the  several  forms  of  malarious 
disease. 


CHAPTER  II. 

INTERMITTENT  FEVER— CHILLS  AND  FEVER. 

Causes. — I will  first  offer  what  I have  to  say  of  the 
causes  of  intermittent  fever  (the  “ fever  and  ague ,”  or 
“ fever  and  agerf  of  many  of  the  country  people) ; then 
proceed  to  give  a description  of  the  several  forms,  patho- 
logy, complications,  sequelae,  treatment,  etc. 

As  my  object  is  a fair  and  impartial  statement  of  facts, 
designing  to  be  plain  and  practical,  I will  not  enter  into 
metaphysical  disquisitions  in  relation  to  what  a majority 
of  authors  of  the  present  day  consider  as  the  essential 
cause  of  this  affection — viz.,  malaria.  What  are  termed 
malarious  diseases  are  generally  considered  to  be  pecu- 
liar to  themselves,  and  acknowledge  the  same  cause  or 
causes,  more  or  less  modified.  They  are  endemic  in 
many  parts  of  the  southern  and  western  States,  as  well 
as  in  many  other  parts  of  the  world,  especially  in  low, 
marshy,  and  swampy  regions ; and  on  nearly  all  the 
principal,  and  many  of  the  smaller  water  courses  in  the 
southern  and  western  States ; but  they  are  not  always 
confined  to  these,  sometimes  making  their  way  into  hilly 
and  mountainous  regions;  indeed,  in  some  elevated  hilly 
places  they  are  endemic.  They  are,  however,  most  ge- 
nerally disposed  to  penetrate  into  hilly  and  mountainous 
regions  when  they  appear  as  an  epidemic  or  endemico- 
epidemic.  Nor  do  they  prevail  as  an  endemic  in  all 
swampy  regions  of  country.  Professor  Dunglison  says: 
“ Districts,  indeed,  similar  to  those  which  in  certain  re- 


INTERMITTENT  FEVER— CAUSES  OF. 


31 


gions  are  known  to  disengage  the  marshy  miasm  in  great 
abundance,  may,  in  other  regions,  be  perfectly  salu- 
brious. It  is  not  every  marsh  that  exhales  the  fitful  pest. 
In  the  eastern  parts  of  this  country,  many  marshes  exist, 
where  agues  are  unknown ; and,  again,  malarious  dis- 
eases prevail  in  fearful  intensity,  in  the  most  pernicious 
form,  where  there  is  no  such  thing  as  a marsh  within 
many  miles.”  Dr.  Cartwright,  of  Natchez,  Mississippi, 
asserts,  that  the  Jussieua  grandifolia,  or  floating  plant  of 
the  bayous  and  lakes  of  Lower  Louisiana,  has  the  power 
of  preventing  the  development  of  malaria  in  regions 
particularly  adapted  to  its  generation;  and,  moreover, 
affirms  that  it  purifies  all  stagnant  water  in  which  it 
grows ; that  of  the  lakes  and  bayous  inhabited  by  it  being 
as  pure  to  the  sight,  taste,  and  smell,  as  if  it  had  just 
fallen  from  the  clouds.  He  ascribes  to  the  presence  of, 
and  the  peculiar  hygienic,  or  health-preserving  proper- 
ties of  this  plant,  the  remarkable  exemption  of  the  inha- 
bitants of  Lower  Louisiana  from  malarious  or  miasmatic 
diseases.  He  says,  the  fact,  that  the  region  of  country 
in  which  this  aquatic  plant  abounds,  is  exceedingly 
healthy,  can  be  established  beyond  cavil  or  dispute,  but 
nevertheless  contains  more  stagnant  water  and  swamps 
than  any  other  inhabited  district,  of  the  same  extent,  in 
the  United  States. 

This  family  of  diseases  have  had  assigned  as  their 
cause,  besides  miasm  or  malaria,  heat  and  moisture, 
warm  days  followed  by  cool,  humid  nights;  carbonic 
acid,  and  sulphuretted  hydrogen  gas;  animalcules ; aerial, 
tellurical,  or  geological  disturbances  or  modifications  in 
electricity;  by  local  irritation,  etc.,  etc.  But  in  the 
present  state  of  our  knowledge,  of  the  qualities,  proper- 
ties, or  nature  of  the  commonly  assigned  cause,  we  may 
confess  our  ignorance.  If  there  is  any  such  thing  as 
miasm,  perhaps,  in  the  march  of  mental  improvement, 


32 


INTERMITTENT  FEVER— CAUSES  OF. 


future  generations  may  be  enabled  to  appreciate  its  pro- 
perties or  its  nature.  Some  writers,  with  plausibility 
too,  deny  the  existence  of  such  a thing.  There  are, 
however,  what  we  may  term  exciting  or  secondary  causes 
(if  there  is  such  a poison  as  miasm,  as  the  chief  or  pri- 
mary cause),  which  we  can  better  appreciate  or  compre- 
hend. Of  these  we  may  mention,  exposure  to  sudden 
vicissitudes  of  weather,  as  high  atmospheric  temperature 
during  the  day,  followed  by  cool,  humid  nights;  intempe- 
rance ; want  of  proper  and  sufficient  nourishment ; lying, 
during  the  night  especially,  in  low,  damp  situations ; and 
everything  which  has  a tendency  to  produce  relaxation 
and  debility.  Exposure  to  the  rays  of  the  sun,  especially 
when  the  weather  begins  to  get  a little  cool  in  autumn ; 
and  eating  muscadines  or  watermelons  late  in  the  season, 
are  noticed  as  causes  by  the  non-professional.  Some 
authors  state  that  inter  mittents  have  been  brought  on 
by  various  crude  ingesta,  and  by  local  irritation,  without 
being  exposed  to  marsh  effluvia.  A case  of  remittent 
fever,  produced  by  a one  grain  weight  in  the  intestines 
of  a child  eighteen  months  old,  is  noticed  in  the  October 
number  of  the  Western  Lancet , for  1848.  This  case  is 
reported  by  Richard  Payne  Cotton.  It  escaped  from  the 
rectum  after  a period  of  six  weeks,  appearing  to  have 
lost  nothing  in  its  transit,  retaining  its  usual  brightness. 

Professor  Dunglison  says  : “ The  health  of  a locality 
is,  likewise,  often  connected  with  the  winds  that  prevail 
during  the  latter  part  of  summer  and  autumn.  In  this 
country,  they  are  chiefly  from  the  southward,  or  have, 
what  the  sailors  term,  southing  in  them.  These  winds 
are  warm,  and,  when  from  the  east,  are  moist  at  the  same 
time.  Inhabitants  of  the  northern  shores  of  our  rivers, 
that  exhale  malaria,  or  to  the  northward  of  any  malarious 
locality,  may,  therefore,  be  expected  to  suffer  more  than 
those  to  the  south  of  those  localities ; and  such  is,  cceteris 


INTERMITTENT  FEVER— CAUSES  OF. 


33 


paribus , the  fact.”  The  reverse  of  this  holds  good, 
generally,  in  the  south-western  States,  at  least,  so  far  as 
the  author’s  observations  extend.  In  this  region  of 
country,  a constant  cool  wind  from  the  north,  in  aguish 
districts,  is  almost  sure  to  bring  about  intermittents,  and 
other  malarious  diseases.  This  is  particularly  noticed, 
not  only  by  physicians,  but  the  people  generally. 
It  has  also  been  observed  that  the  inhabitants  on  the 
north  side  of  a river  suffer  more  from  malarious  diseases 
when  the  wind  is  from  the  south,  and  that  both  sides  of 
a river,  which  runs  westwardly  or  eastwardly,  are  seldom 
or  never  equally  sickly  at  the  same  time.  These  remarks 
apply  particularly  to  the  Tennessee  River  Valley  in 
North  Alabama.  I have  heard  it  suggested  that  the  more 
malignant  or  congestive  forms  of  malarious  fever,  were 
not  known  in  this  country  till  since  the  epidemic  or 
Asiatic  cholera  visited  this  continent.  Though  conges- 
tive fever  appears  to  have  been  much  more  common  since 
this  time,  and  more  particularly  noticed  by  that  name, 
yet  it  was  observed  in  this  country  prior  to  the  visitation 
of  the  cholera. 

As  a means  of  prophylaxis,  many  southern  planters 
are  in  the  habit  of  leaving  a woodland  surrounding  their 
residences,  or  especially  between  their  dwellings  and  any 
swamp  that  may  be  near,  which  is  suspected  to  generate 
the  marsh  poison  or  miasm.  Though  this  does  not  secure 
immunity,  it  perhaps  renders  them  somewhat  less  liable. 
It  would  seem  that  the  ancients  entertained  similar  views 
as  to  the  protective  influence  of  forests,  and,  therefore,  it 
has  been  supposed  that  the  woods  in  the  vicinity  of  Rome 
were  consecrated  to  Neptune,  to  secure  them  from  the 
axe.  If  the  Jussieua  grandifolia  has  the  powers  ascribed 
to  it  by  Dr.  Cartwright,  would  not  its  propagation  in  all 
our  swampy,  malarious  districts,  be  one  of  the  greatest 
blessings  to  the  inhabitants  of  these  regions  ? and  almost 


34 


INTERMITTENT  FEVER— CAUSES  OF. 


induce  them  to  suppose,  if  they  were  believers  in  ancient 
mythology,  that  most  of  the  Fates,  which  escaped  from 
Pandora's  box,  were  destroyed  by  this  aquatic  plant ; as 
the  less  informed  Irishman  believes  that  St.  Patrick 
destroyed  all  the  frogs  and  serpents  in  Ireland,  and  ren- 
dered that  island  uninhabitable  by  these  animals? 

I have  sometimes  been  led  to  notice,  that  a removal 
from  a malarious  district  to  a healthy  one,  during  what 
may  be  supposed  to  have  been  the  latent  period,  ap- 
parently has  a tendency  to  develop  some  form  of  mala- 
rious disease.  If  this  be  true,  it  is  a curious  fact. 
Professor  Dickson’s  observations  appear  to  corroborate 
this  idea.  He  says,  “ It  has  been  a long  received  opinion 
that  a return  to  our  comparatively  healthy  city  (Charles- 
ton) atmosphere,  the  ordinary  summer  residence  of  so 
many  planters,  during  the  latent  period  which  ensues 
after  efficient  exposure,  as  above  described,  endows  the 
coming  attack,  in  some  obscure  manner,  with  a peculiar 
violence  and  malignity,”  and  that  the  type  “ is  apt  to  be 
irregular,  confused,  and  complicated and  further,  “a 
similar  aggravation  of  violence  and  danger  is  affirmed  to 
occur  everywhere,  when  a subject  efficiently  exposed  to 
the  influence  of  febrific  miasmata,  has  removed  during 
the  latent  period  to  a pure  and  salubrious  atmosphere. 
This  is  true,  as  Flint  tells  us,  of  the  upland  prairies  of 
the  far  West,  and  as  I have  more  than  once  had  occasion 
to  note,  in  our  own  lofty  mountain  regions.” 

Some  who  have  had  an  attack  of  intermittent  fever  one 
summer  or  autumn,  appear,  under  favorable  circum- 
stances for  its  development,  to  have  acquired  a proclivity 
or  obnoxiousness  to  it  the  next  succeeding  summer  or 
fall,  and  hence  some  authors  have  made  an  annual  va- 
riety of  intermittent  fever. 

Before  noticing  the  different  stages  of  a paroxysm  of 
intermittent  fever,  I will  notice  what  may  be  considered 


INTERMITTENT  FEVER— PRODROMIC  FORM  OR  TYPE.  35 


the  prodromic  form  or  type  of  malarious  disease.  This 
is  indicated  by  a slight  feeling  of  malaise , or  restlessness, 
feverishness,  headache ; slight,  rather  obtuse  pains  or 
aching  in  the  loins,  and  sometimes  elsewhere  ; nervous- 
ness, sometimes  alternated  with,  or  followed  by  flushes 
of  heat,  dryness  and  moisture  of  the  skin.  If  these 
disturbances  t^ke  place  about  meal  time,  the  appetite  is 
noticed  to  be  not  good,  much  less  food  than  usual  suffi- 
cing for  the  repast.  The  fingers  and  toes,  during  these 
irregular  nervous  disturbances,  are  apt  to  be  a little  cool, 
and,  perhaps,  generally  moist,  especially  the  feet,  and 
sometimes  other  portions  of  the  body ; but  probably  most 
frequently  not  noticed  by  the  patient,  unless  the  attention 
be  particularly  pointed  to  them  by  interrogatories.  A 
feeling  of  drowsiness,  or  slight  languor,  or  headache  may 
ensue.  These  slight  disturbances,  sometimes  so  slight 
as  scarcely  to  attract  attention,  may  recur  about  the  same 
time  every  day,  every  other  day,  or  at  irregular  periods, 
for  several  days,  a week  or  more,  and  sometimes  pass  off; 
but  frequently,  if  not  attended  to,  is  soon  developed  into 
a distinct  paroxysm  of  intermittent,  remittent,  or  conges- 
tive fever. 

R.  S.  Holmes,  M.  D.,  Med.  Staff,  U.  S.  A.,  in  his  Re- 
marks on  the  use  of  quinine  in  Florida,  and  on  malaria 
and  its  influence  in  that  State,  says : “ I believe  there  is 
scarcely  a person  even  in  good  health  in  a miasmatic  re- 
gion, who  is  not  subjected  in  some  degree  to  the  effects 
of  the  unseen  agent  around  him.  His  rest  will  be  broken 
at  night;  his  appetite  will  not  be  so  good  as  formerly; 
he  will  not  enjoy  that  feeling  of  full  health  he  has  been 
accustomed  to;  his  system  will  be  attacked  from  time  to 
time  by  the  offshoots  of  the  diseases  preying  on  others 
around  him,  though  he  will  not  be  sick,  and  may  escape 
with  a like  freedom  from  disease  during  all  his  sojourn 
in  the  country  : but  the  whole  constitution  seems  in  some 


36  INTERMITTENT  FEVER— PRODROMIC  FORM  OR  TYPE. 

degree  to  labor  under  the  influence  of  malaria.  Slight 
wounds,  that  would  heal  elsewhere  in  a few  days’  time, 
must  here  undergo  the  slow  process  of  suppuration  and 
granulation,  and  even  this  does  not  come  on  easily,  the 
wound  remaining  for  several  days  without  any  visible 
advance  towards  a cure.  You  cannot  persuade  a slight 
incision  of  the  skin  to  heal  by  adhesive  inflammation ; 
and  I have  repeatedly  seen  wounds  in  habits  that  were 
to  all  intents  healthy,  assume  a deep,  burrowing  suppu- 
ration. I was  in  the  habit  at  first  of  discharging  patients 
when  the  wound  had  closed  by  granulations,  if  not  on  an 
important  part  of  the  body,  and  not  interfering  with  com- 
mon duties ; but  on  the  slightest  exercise  or  excitpment, 
inflammation  would  set  in  afresh,  in  surrounding  parts; 
the  granulations  would  assume  an  unhealthy  appear- 
ance; suppuration,  if  advanced,  would  be  slow  in  pro- 
gress, and  of  an  unhealthy  form  : perfect  rest,  good  diet, 
occasionally  tonics ; and  poultices  or  stimulants  to  the 
part,  were  necessary  for  a cure.  Many  of  these  wounds, 
especially  about  the  fingers,  ran  rapidly  into  deep-seated 
inflammations.  A miasmatic  constitution  of  the  atmos- 
phere is  particularly  favorable  to  the  formation  of  whit- 
lows. I treated  these  by  deep  incisions,  and  generally, 
some  hours  after,  sprinkled  the  part  over  with  calomel ; 
but  the  first  incisions  scarcely  ever  proved  sufficient;  the 
suppuration  would  extend  beyond  them.  The  pain  of 
these  whitlows  will  take  on  regular  remissions.” 

This  prodromic  form  or  type  of  malarious  derangement 
may  be  easily  cured  by  quinine  or  other  tonics,  it  some- 
times being  necessary  to  take  an  aperient.  Some  phy- 
sicians, when  busily  engaged  in  practice,  if  they  feel 
some  of  the  manifestations  of  this  prodromic  form  or  type, 
are  in  the  habit  of  immediately  taking  a dose  of  quinine. 

I have  thought  it  proper  to  consider  this  condition 
first,  and  separately,  because  those  thus  affected  are  not 


INTERMITTENT  FEVER— SYMPTOMS— COLD  STAGE.  37 

prevented  from  attending  to  their  ordinary  business,  and 
it  frequently  attracts  so  little  attention,  unless  its  milder 
manifestations  are  increased  to  greater  disturbances,  that 
its  treatment  is  often  neglected,  which,  if  it  had  been  at- 
tended to,  might  have  averted  an  attack  of  intermittent, 
remittent,  or  congestive  fever. 

Before  a paroxysm  of  any  of  the  types  of  intermittent 
fever  occurs,  it  is  generally,  if  not  always,  preceded  by 
'precursory  symptoms  ; as,  aching  in  the  loins,  with  ner- 
vous sensations  running  up  and  down  the  same ; which 
some  have  likened,  for  want  of  a better  simile,  to  cold 
water  trickling  down  the  loins ; yawning,  stretching ; 
being  a little  cool,  with  a disposition  to  draw  near  the 
tire,  etc.  Sometimes  pains  in  the  limbs  or  joints,  slight 
headache,  indisposition,  lassitude,  the  fingers  and  toes 
become  cool,  and  the  features  are  generally  somewhat 
pallid.  To  these  soon  succeeds, 

1.  The  Cold  Stage,  Chill,  or  Rigor,  sometimes 
merely  attended  with  an  uncomfortable  sensation  of  cold- 
ness, especially  of  the  hands  and  feet,  and  a feeling  of 
uncomfortableness  and  oppression  ; at  others  stretching, 
gaping,  and  drawing  near  the  fire,  with  an  involuntary 
shivering  or  shaking  of  the  whole  body,  more  or  less  in- 
tense, at  times  causing  chattering  of  the  teeth.  The 
aching  and  trickling  sensations  of  the  back,  noticed 
during  the  premonitory  stage,  are  augmented.  There 
is  generally  a disposition  to  draw  the  knees  and  chin 
near  each  other,  as  though  the  patient  wished  to  get  into 
as  small  a compass  as  possible ; the  skin  is  pale,  and 
generally  of  a rather  purplish  or  muddy  hue,  though  in 
other  cases  slightly  tinged  with  a yellowish  hue.  These 
are  more  distinct  on  some  parts  than  others ; as  the  lips, 
about  the  face  and  neck,  fingers,  particularly  blueness  of 
the  nails,  &c.  The  cutaneous  surface  also  becomes  con- 


38 


INTERMITTENT  FEVER— SYMPTOMS. 


tracted,  wrinkled,  more  or  less  rough;  which  condition 
has  been  called  cutis  anserina , or  goose  skin.  The  cold, 
chilly,  benumbed  sensations  of  the  patient,  are  not  always 
in  accordance  with  the  actual  reduction  of  the  tempera- 
ture of  the  surface.  The  sensations  of  the  patient  may 
incline  him  to  believe  that  he  is  very  cold,  when  to  the 
hand  of  any  of  his  attendants  there  appears  to  be  little  or 
no  alteration  of  the  temperature  of  the  surface;  or  the  pa- 
tient may  correctly  appreciate  the  degree  of  coldness; 
or  he  may  feel  cool,  when  to  the  touch  of  another  he  is 
warmer  than  natural,  especially  about  the  chest;  or  he 
may  feel  hot  when  he  is  cool.  The  sensible  perspiration 
is  suspended ; the  pulse  is  small,  weak,  contracted  ; but 
in  the  sanguine  temperament  may  be  rather  firm,  and  is 
generally  increased  in  frequency.  Respiration  is  embar- 
rassed, irregular,  and  increased  in  frequency,  with  a full 
inspiration  or  deep  sigh  occasionally,  in  some  cases  at- 
tended with  a short,  dry  cough  ; a sensation  of  oppres- 
sion ; enfeebled  and  tremulous  voice.  In  some  cases,  a 
sensation  of  weight  or  heaviness,  pain  and  distressing 
nausea  of  the  stomach,  at  times,  in  some  cases,  attended 
with  vomiting  of  a ropy,  glairy  mucus;  and,  if  the  vo- 
miting continues  for  some  time,  succeeded  by  yellowish 
bile,  and  sometimes  even  blood;  a wild  stare  of  the  eyes; 
great  desire  for  cold  drinks;  the  mouth  and  fauces  rather 
dry  and  clammy ; cramps  of  the  stomach  and  abdomen, 
and  upper  and  lower  extremities.  Urine  usually  co- 
pious and  clear. 

Though  some  or  all  of  the  above  symptoms  usually 
characterize  the  cold  stage,  yet  others  sometimes  occur, 
which  are  commonly  regarded  as  anomalies , and  which 
we  will  notice  presently. 

The  duration  of  the  cold  stage  is  very  various,  in  some 
cases  lasting  only  a few  minutes,  in  others  one,  two, 
three,  four,  or  five  hours,  or  longer.  I believe  those  cases 


INTERMITTENT  FEVER— SYMPTOMS. 


39 


in  which  the  cold  stage  is  several  hours  long,  are  apt  to 
be  attended  with  great  distress  of  the  stomach,  nausea 
and  vomiting,  but  this  is  not  always  so. 

In  many  cases  the  mental  functions  are  increased, 
ideas  passing  through  the  mind  with  unusual  rapidity, 
with  concomitant  restlessness,  confusion  and  irritability 
of  mind,  and  sometimes  slight  delirium : this  is  more 
likely  to  occur  in  those  of  a sanguine  or  excitable  tem- 
perament ; while  it  is  common  for  those  of  a leuco-phleg- 
matic  temperament,  especially  after  they  have  had  ague 
for  a long  time,  to  be  dull,  careless,  manifesting  a taciturn 
moroseness ; and  this  stage  in  them  is  frequently  charac- 
terized only  by  cold  extremities  and  dulness.  In  those 
of  full  habit,  stupor  or  coma  is  sometimes  induced,  but 
this  is  more  apt  to  be  the  case  on  the  approach  of,  or 
during  the  next  stage,  the  stage  of  excitement. 

During  the  cold  stage,  the  whole  body  is  diminished 
in  volume ; rings  on  the  fingers,  which  were  previously 
tight,  become  loose,  and  tumors  near  the  surface  are  re- 
duced in  size. 

But  it  must  not  be  supposed  that  all  the  above  symp- 
toms or  phenomena  are  to  be  met  with  in  every  case. 
In  some  cases  there  are  only  slight  sensations  of  chilli- 
ness creeping  along  the  loins,  with  cool  hands  and  feet, 
with  some  degree  of  restlessness  or  languor ; and  even 
these  are  sometimes  scarcely  noticed.  The  degree  of 
excitement  cannot  be  anticipated  by  the  intensity  or  se- 
verity of  the  cold  stage,  chill,  or  rigor.  Sometimes  the 
reaction  will  be  as  great  when  the  feet  and  hands  have 
merely  been  observed  to  be  a little  cool,  with  perhaps 
some  creeping,  nervous  sensations  in  the  back,  slight 
nervous  agitation,  or  feeling  of  uncomfortableness,  as 
when  the  rigor  is  very  severe.  And  here  I wish  to  re- 
mark, and  desire  that  especial  attention  be  paid  to  it, 
that  infants,  and  young  children  generally,  merely  have 


40 


INTERMITTENT  FEVER— SYMPTOMS. 


cool  hands  and  feet , sometimes  attended  with  restlessness , 
respiration  somewhat  embarrassed , and  quickness  or  ir- 
regularity of  the  pulse , during  the  cold  stage  of  intermit- 
tents : and  as  the  coolness  of  the  extremities  is  fre- 
quently overlooked,  or  not  noticed  by  the  parent  or 
attendant  physician,  they  are  puzzled  to  properly  appre- 
ciate the  nature  of  the  affection ; and,  in  consequence 
thereof,  an  improper  course  of  treatment  may  be,  and  not 
unfrequently  is,  adopted.  It  is  also  said  that,  in  young 
children,  a paroxysm  is  sometimes  ushered  in  by  con- 
vulsions, but  this  is  more  apt  to  occur  at  the  commence- 
ment of  the  hot  stage. 

In  some  cases  the  febrile  condition  precedes  the  chilly 
sensations.  This  was  the  case  with  the  writer  in  the 
latter  part  of  August,  1848.  About  twilight  one  evening 
some  slight,  chilly  sensations  came  on,  which  were  fol- 
lowed by  fever ; the  second  evening  afterwards  a febrile 
condition  came  on ; and  some  twenty-five  or  thirty  minutes 
afterwards,  chilly  sensations,  with  the  peculiar  sensations 
in  the  loins  were  felt,  w’hile  the  febrile  excitement  con- 
tinued. Indeed,  it  is  not  unfrequently  the  case,  that  the 
chilly  feeling  and  febrile  condition  are  concomitant  in 
their  inception,  the  former  passing  off  after  an  indefinite 
length  of  time.  This  form  is  perhaps  analogous  if  not 
identical  with  the  epialos  of  the  ancient  Greeks. 

It  would  be  impossible  to  describe  all  the  various  modi- 
fications and  phenomena  which  at  times  manifest  their 
appearance  in  the  cold  stage  of  intermittents.  In  order 
to  fully  appreciate  them,  it  is  necessary  that  one  should 
practice  a sufficient  length  of  time  in  a malarious  region 
of  country,  and  observe  closely  and  carefully  for  himself ; 
and  he  may  be  much  assisted  by  frequent  conversations 
and  communications  with  his  brother  practitioners. 

Most  commonly,  as  the  chilly  feelings  begin  to 
abate,  transient  flushes  of  heat  make  their  appearance. 


INTERMITTENT  FEVER— HOT  STAGE. 


41 


which  become  more  and  more  permanent ; the  heat  of 
the  body  is  first  augmented,  and  then  extends,  pari 
passu , to  the  head  and  extremities ; the  reverse  of  this 
having  taken  place  during  the  cold  stage.  It  has  been 
remarked  that  the  nausea  and  vomiting  are  commonly 
most  apt  to  be  severe  at  this  time. 

2.  The  Hot  Stage,  or  Stage  of  Expansion,  as  it  has 
been  termed,  which  succeeds  the  cold  stage,  is  charac- 
terized by  a full  and  flushed  countenance,  quickness  of 
the  mental  functions,  pain  in  the  forehead,  and  headache, 
most  commonly;  restlessness,  mobility,  and  in  some 
cases  slight  delirium ; or  a disposition  to  coma  and 
lethargy;  aching  in  the  loins,  and  sometimes  in  the  ex- 
tremities and  joints.  The  respiration  is  still  embarrassed, 
hurried,  and  oppressed,  but  in  a less  degree  than  in  the 
preceding  stage.  The  pulse  becomes  more  full  and  de- 
veloped, still  being  increased  somewhat  in  rapidity;  in 
some  cases  the  carotids  are  seen  to  beat  with  augmented 
force  and  frequency,  especially  in  those  of  a sanguine 
temperament,  or  those  who  have  recently  arrived  from  a 
more  healthy  region  of  country.  In  these,  it  is  more  apt 
to  assume  what  has  been  called  the  inflammatory  variety 
of  intermittent  fever.  In  many  of  those  whose  systems 
have  become  debilitated  and  relaxed  from  a long  residence 
in  a warm  and  malarious  country,  the  pulse  is  not  usually 
so  full  and  hard  as  might  be  expected  by  those  who  prac- 
tice in  more  northern  and  healthy  regions.  The  skin  is 
dry , hot,  and  accompanied  with  embonpoint,  or  fulness; 
the  mouth  dry  and  clammy,  and  the  breath  warmer  than 
natural.  The  sensation  of  heat  is  variable,  sometimes 
considerably  augmented,*  at  others  but  little  more  than 
natural.  At  this  time,  in  most  cases,  there  is  more 

* Fordyce  observed  the  temperature  of  the  surface  as  high  as  105°  Fahr. 

4 


42 


INTERMITTENT  FEVER— HOT  STAGE. 


or  less  restlessness,  and  a disposition  to  throw  off  the  bed- 
clothes, in  order  that  the  body  may  he  exposed  to  a cool 
atmosphere ; but  in  some  there  is  an  indifference,  dul- 
ness,  and  stupidity,  more  especially  in  those  who  have 
had  the  disease  a long  time,  and  have  become  cachectic, 
with  concomitant  visceral  disease.  In  some  cases  the 
fever  is  so  mild  that  the  patient  is  able  to  walk  about, 
feeliim  nervous  and  feeble. 

O 

The  gastric  disturbance  at  the  commencement  of  this 
stage  usually  gradually  subsides,  and  is  succeeded  by 
cephalalgia,  or  pain  in  the  head,  which,  in  the  robust  and 
sanguine  temperament,  is  sometimes  very  intense.  The 
urine  is  scanty  and  high  colored,  depositing  little  or  no 
sediment,  and  of  a sort  of  pungent,  rancid  odor. 

The  duration  of  the  hot  stage  is  very  various,  but 
generally  longer  than  the  cold  stage.  Not  unfrequently 
it  passes  off  in  two  or  three  hours,  and  the  individual 
gets  up  and  walks  about,  or  attends  to  some  light  work 
or  business;  frequently  it  lasts  for  four,  six,  or  eight 
hours,  or  more,  which  is  usually  succeeded  by  a greater 
degree  of  weakness  and  languor.  Sometimes  this  stage 
becomes  more  and  more  protracted  at  each  paroxysm,  till 
this  form  of  fever  is  merged  into  the  remittent  form. 

The  above  may  be  considered  the  usual  manifestations 
or  attendant  phenomena  of  the  cold  and  hot  stages  of  in- 
termittent fever,  but  they  are  not  always  uniformly  so; 
some  of  them  may  be  wanting,  and  other  anomalous  phe- 
nomena, more  or  less  common,  manifest  themselves;  as 
cramp  and  intense  pain  of  the  stomach,  and  palpitations 
of  the  heart,  connected  with  cold  hands  and  feet;  griping 
pains  in  the  bowels;  intense  pain  in  some  part  of  the 
body,  which  may  be  more  or  less  migratory,  coming  on 
by  spells,  with  intervals  of  partial  or  entire  relief.  Indeed, 
almost  every  form  of  neuralgia  may  be  indicative  of  the 
malarious  influence ; frontal  neuralgia,  or  headache , which 
returns  every  day,  or  every  other  day,  at  about  the  same 


INTERMITTENT  FEVER— ANOMALOUS  VARIETIES. 


43 


time  of  day,  is  not  unfrequently  observed.  Sometimes 
we  observe  dor so-inter costal  neuralgia , hepatalgia , hemi- 
crania , toothache,  some  form  of  rheumatism,  hiccough, 
mania,  etc.  etc.;  and  these  are  observed  to  recur  at  par- 
ticular times,  with  as  much  regularity  as  a well-marked 
case  of  quotidian  or  tertian  intermittent,  and  yield  to  the 
same  remedies  as  these  latter.  These  are  the  mashed 
agues,  febres  intermittentes  larvatce,  of  authors,  or  dumb 
ague,  of  the  non-professional ; but  I believe  a goodly  num- 
ber of  the  unprofessional,  call  a case  the  “ dumb  ague,” 
when  the  cold  stage  is  scarcely  perceived,  attended  with 
languor.  Diarrhoea  and  dysentery  not  unfrequently 
attend  some  of  the  manifestations  of  malarious  influence  ; 
and  cholera  is  also  mentioned  by  some  authors. 

Dr.  Eberle  says:  “In  some  instances,  anomalies  of  a 
remarkable  character  occur,  both  in  relation  to  the  phe- 
nomena and  the  succession  of  the  stages  of  the  disease. 
I have  known  a case,  in  which  the  first  two  paroxysms 
occurred  in  a perfectly  regular  manner ; but  after  em- 
ploying arsenic,  unsuccessfully,  during  the  second  and 
third  intermissions,  the  paroxysms  returned  without  a 
cold  stage,  the  patient  experiencing,  instead  of  it,  a pecu- 
liar feeling  of  numbness  on  the  top  of  the  head,  with 
great  dulness  of  hearing,  for  about  forty  or  fifty  minutes 
before  the  supervention  of  the  hot  stage.  There  are  in- 
stances on  record,  of  the  inversion  of  the  natural  order  of 
the  cold,  hot,  and  sweating  stages;  several  distinct  in- 
stances of  which  occurred  under  my  observation  in  the 
fall  of  1828.  Cases  have  been  noticed,  in  which  the 
perspiration,  in  the  third  stage,  was  substituted  by  diar- 
rhoea ; and  Cleghorn  states  that  he  saw  tertians,  which 
terminated  by  an  increased  flow  of  urine,  with  scarcely 
any  sweat.”  But  I will  return  from  this  digression,  and 
notice  what  is  commonly  considered  the  last  stage  of  the 
paroxysm,  namely — 


44  INTERMITTENT  FEVER— ANOMALOUS  VARIETIES. 

3.  The  Sweating  Stage,  which  usually  commences 
with  moisture  of  the  forehead  and  temples,  neck,  axilla, 
chest,  inner  part  of  the  thighs,  soon  becoming  general ; 
sometimes  being  very  copious,  and  not  only  soaking  the 
body  linen,  but  even  the  bed-clothes ; in  other  cases,  there 
is  but  a gentle  perspiration,  or  there  may  only  be  mois- 
ture on  some  parts  of  the  body.  When  it  is  copious,  it 
has  a sort  of  flat,  funky  smell;  when  scanty,  or  slight, 
less  so,  and  more  pungent. 

The  patient  gets  better  soon  after  the  commencement 
of  this  stage ; the  hot  skin  of  the  former  stage  now  as- 
sumes its  normal  temperature,  or  may  even  feel  a little 
cooler  to  another  person  ; the  pains  and  oppression  gra- 
dually disappear  ; the  respiration  becomes  free  and  easy  ; 
the  pulse  full  and  soft,  and  but  little,  if  any  more  frequent 
than  natural.  In  fact,  the  patient  is  every  way  relieved. 
The  urine  is  now  more  or  less  high  colored,  and  deposits 
a lateritious  or  pale  red  sediment ; the  odor  above  no- 
ticed may  also  be  perceived,  somewhat  modified  perhaps. 
“ This  gradual  melioration  of  the  febrile  symptoms  con- 
tinues under  the  free  flow  of  the  perspiration,  until  the 
paroxysm  terminates  in  a state  of  perfect  convalescence,  or 
apyrexia .”  ( Eberle .) 

Dr.  Billing  does  not  consider  this  stage  entitled  to  the 
appellation,  or  says  there  is  no  third  stage,  the  sweat 
being  “ nothing  but  an  indication  of  renewed  secretion 
by  the  capillaries ; which,  after  having  lost  their  tone, 
and  been  consequently  in  a relaxed,  disturbed,  non-se- 
creting state,  renew  their  secretion  on  being  restored  to  a 
normal  condition.” 

The  above-mentioned  three  stages  are  said  to  consti- 
tute a 'paroxysm , or  Jit. 

The  paroxysm  being  over,  the  patient  may  feel  en- 
tirely well  during  the  apyrexia,  though  usually  rather 


INTERMITTENT  FEVER— TYPES. 


45 


weak,  languid,  lazy,  or  averse  to  bodily  exertion  ; with,  in 
some  cases,  hebetude  of  the  sensorial  or  mental  powers ; 
looks  pale  and  sickly  ; is  very  susceptible  to  the  influence 
of  cold;  is  easily  fatigued  by  exertion  or  labor;  the  appe- 
tite is  generally  impaired,  but  in  some  protracted  or  chro- 
nic cases  it  is  very  voracious. 

The  duration  of  the  period  of  apyrexia  is  modified  by 
the  length  of  the  paroxysm,  the  type  of  the  intermittent, 
and  the  means  that  may  be  used  to  avert  the  next  paroxysm. 

Types. — Intermittent^  having  a disposition  to  recur  at 
certain  times,  has  given  rise  to  distinctive  appellations 
which  indicate  the  type  ; as,  the  quotidian , which  returns 
every  day,  or  every  twenty-four  hours ; the  tertian , every 
other  day;  the  quartan , every  third  day.  The  double 
quotidian  has  two  paroxysms  every  day ; the  first  one 
corresponding  with  the  first  one,  and  the  second  the 
second  one,  the  day  previous.  The  double  tertian  has  a 
paroxysm  every  day,  the  paroxysms  of  every  other  day 
corresponding.  These  are  the  principal  types,  though 
others  are  noticed,  especially  irregular  ones,  which  ob- 
serve no  particular  time  in  their  recurrence,  but  are  apt 
to  simulate,  in  some  degree,  some  of  the  other  types,  at 
least  for  a time,  and  then  there  may  be  an  interval  of 
several  days.  Double  quartans,  triple  quotidians , triple 
and  quadruple  tertians  occur  but  seldom.  Authors  men- 
tion the  quintan,  sextan , hebdomadal , octan,  nonan , men - 
sual,  bimensual,  tnmensual , annual,  etc.  If  the  paroxysm 
recurs  after  an  interval  of  more  than  three  days,  I am 
inclined  to  believe  that  they  should  generally  be  regarded 
as  relapses,  or  a return  of  the  disease ; and  this  is  more 
apt  to  take  place  if  the  preceding  attack  has  induced 
some  local  visceral  disease  and  debility ; or  the  indivi- 
dual is  still  exposed  to  the  causes  of  intermittents. 

Not  unfrequently  one  type  changes  to  another ; and  this 


46 


INTERMITTENT  FEVER— TYPES. 


reciprocity  or  interchanging  is  most  common  among  the 
different  varieties  of  quotidians  and  tertians ; and  these 
are  also  more  liable  to  run  into  the  remittent  or  conges- 
tive fever ; and  these  latter,  by  treatment,  may  be  made 
to  assume  some  of  the  intermittent  types.  Remittent 
fever,  especially  in  some  instances  when  it  appears  as  an 
epidemic,  is  sometimes  easily  changed  to  the  intermittent 
form,  by  a venesection.  Intermittent  fever  is  also  apt  to 
ensue  after  a remittent  has  been  cured,  especially  if  the 
case  occur  in  a highly  malarious  district,  and  proper  at- 
tention is  neglected. 

One  paroxysm  may  follow  another  in  a short  time,  by 
exposure  and  fatigue;  indeed,  these  may  bring  on  a 
second  chill  before  the  paroxysm  is  over.  An  individual 
may  have  three,  four,  five,  or  more  chills  in  one  day ; 
again  he  may  have  a chill  one  day,  and  not  another  for 
several  days  afterwards;  and  then  he  may  have  several  in 
pretty  close  succession;  and  then  they  may  again  disap- 
pear for  an  indefinite  length  of  time,  or  entirely.  Many 
respectable  medical  writers  speak  of  the  strong  proclivity 
of  intermittents  to  relapse  at  certain  intervals,  as  the 
seventh,  fourteenth,  or  twenty-first  days;  and  also  re- 
mark that  they  are  more  easily  and  permanently  cured 
by  the  exhibition  of  the  proper  remedies  at  these  pe- 
riods. In  this,  there  appears  at  least  some  inconsistency, 
some  fixing  one  period  and  some  another.  As  I have 
known  intermittents  to  recur  or  return  at  so  many  and 
various  periods,  I am  inclined  to  consider  these  notions 
as  relics  of  ancient  superstition.  A believer  in  these  cri- 
tical days,  having  his  mind  more  particularly  directed  to 
them,  may  observe  the  recurrence  of  a paroxysm  on  those 
days,  while  many  others  may  escape  his  attention. 

When  the  paroxysm  comes  on  earlier  in  the  day  than 
the  preceding  paroxysm,  it  is  said  to  be  anticipating; 
when  later,  postponing.  If  one  begins  before  the  prece- 


INTERMITTENT  FEVER— PATHOLOGY. 


47 


ding  one  terminates,  the  fever  is  said  to  be  subintrant. 
Those  of  this  nature  are,  perhaps,  closely  allied,  if  not 
identical  with  the  amphemerina  of  the  Greeks. 

As  to  complicated  intermittents,  it  would  seem  that  the 
malarious  influence  may  attach  itself  to  almost  every 
form  of  organic  or  constitutional  disease,  and  as  this  is 
of  very  frequent  occurrence,  I consider  it  of  much  im- 
portance to  those  who  have  recently  commenced  practice 
in  a malarious  region,  in  order  that  they  may  appreciate 
this  twofold  condition,  and  combine  their  remedies  so  as 
to  fulfil  this  double  indication.  Visceral  affections,  dysen- 
tery, jaundice,  paralysis,  apoplexy,*'  epilepsy,  and  the 
various  neuralgias  may  bbSregarded  as  complications. 

The  various  forms  of  malarious  neuralgia,  if  I may  be 
allowed  the  expression,  Which  strictly  observe  a periodi- 
cal recurrence  (perhaps  a majority  of  them  observe  the 
quotidian  type),  are  generally  preceded  by  some  of  the 
mildest  premonitory  symptoms  of  ague  ; as,  a feeling  of 
nervousness,  or  slight  chilliness  ; the  feet  are  apt  to  get 
cool  and  moist,  perhaps  the  fingers  also,  and  moist  skin, 
etc.  etc. ; and  after  the  paroxysm  is  over,  the  urine  is  apt 
to  be  turbid  ; during  the  paroxysm  clear,  and  sometimes 
copious,  especially  in  nervous  females. 

Pathology. — If  intermittent  fever  and  other  malarious 
affections  are  caused  by  any  material  substance,  as  miasm, 
malaria,  poisonous  gas  of  any  kind,  animalculae,  or  any- 
thing floating  in  the  atmosphere,  it  appears  most  rea- 
sonable to  suppose  that  it  is  inhaled  into  the  lungs  with 
the  air  in  inspiration,  there  absorbed,  admitted  into  the 
circulating  fluid,  the  blood,  on  which  it  probably  in- 

* This  malarious  influence,  in  reference  to  the  pathological  condition  of 
the  brain,  should,  perhaps,  be,  regarded  as  a sort  of  nervous  apoplexy  (if  it 
is  entitled  to  the  appellation  of  “ apoplexy ” at  all),  entirely  distinct  from 
true  apoplexy. 


48 


INTERMITTENT  FEVER— PATHOLOGY. 


duces  some  morbid  change,  or  is  carried  by  it  to  the 
nervous  centres , where  it  apparently  first  manifests  its 
morbid  influence;  or  this  derangement  of  the  nervous 
centres  may  be  the  result  of  pathological  changes  that 
have  taken  place  in  the  blood  : indeed,  the  position  that 
the  poison  is  inhaled  into  the  lungs,  and  there  admitted 
into  the  circulation,  appears  tacitly  to  acknowledge,  that, 
during  the  latent  period,  some  morbid  change  may  be 
going  on  in  the  blood.  If  malarious  affections  are  caused 
by  the  sensible  or  appreciable  conditions  of  the  atmo- 
sphere, as  heat  and  cold,  and  humidity,  or  by  electrical, 
tellurical,  or  geological  disturbances,  it  would  seem  that 
the  primary  morbid  influence  is  exerted  an  the  nervous 
centres,  and  thence  on  the  nervous  system  generally  ; and 
then,  as  a matter  of  course,  the  whole  system  partici- 
pates to  a greater  or  less  extent  in  the  derangement. 

In  the  present  state  of  our  knowledge,  as  to  the  precise 
nature  of  these  morbid  impressions,  we  can  only  draw 
inferences  from  the  effects,  and  these  may  be  correct  or 
otherwise.  Whatever  is  the  primary  impression,  it  ap- 
pears that  the  nervous  centres  are  so  affected  as  to  pre- 
vent them  from  generating  regularly  the  normal  amount 
of  nervous  fluid,  or  that  which  gives  nervous  power 
(call  it  by  whatever  name  you  may);  hence,  there  is  a 
want  of  equilibrium  in  the  nervous  functions,  or  func- 
tions of  the  different  parts  of  the  nervous  system,  and 
this  is  soon  succeeded  (and  probably  attended  from  the 
beginning  at  the  nervous  centres)  by  manifest  distur- 
bances of  the  circulation,  as  is  evinced  by  the  phenomena 
of  a rigor  most  unequivocally.  This  being  the  case,  we 
need  not  be  surprised  that  those  organs  situated  inter- 
nally, of  a soft  or  spongy  nature,  and  freely  supplied  by 
large  blood-vessels,  their  nervous  power  considerably  les- 
sened, should  suffer  from  congestion  or  hypersemia,  and 
consequent  enlargement,  as  is  most  commonly  observed 


INTERMITTENT  FEVER— PERIODICITY. 


49 


of  the  spleen.  The  liver,  lungs,  kidneys,  brain,  heart, 
etc.  etc.,  and  even  the  larger  vessels  themselves,  may 
suffer  from  congestion.  Hence  we  observe  that  the  in- 
tensity  and  seriousness  of  visceral  diseases,  as  complica- 
tions, are  in  the  ratio  of  the  intensity  and  frequency  or 
repetition  of  the  paroxysms.  In  this  general  derange- 
ment of  the  nervous  and  circulatory  systems,  the  capilla- 
ries become  affected,  and  the  different  secretory  functions 
are  disturbed. 

Periodicity  of  Malarious  Diseases. — As  to  the 
cause,  or  the  laws  that  govern  the  periodical  recurrence 
of  intermit flents,  and  affections  of  a kindred  nature, 
though  plausible  conjectures  may  be  offered,  nothing  en- 
tirely and  wholly  satisfactory  is  known.  Professor  Dun- 
glison  makes  the  following  remarks,  which  in  part,  I 
believe,  were  expressed  by  Sydenham.  “ We  know  no- 
thing of  the  causes  of  that  periodicity,  which  is  observed 
in  the  action  of  various  organs  in  health,  any  more  than 
of  those  which  constitute  the  essence  of  various  periodi- 
cal diseases.  There  is  probably  a periodical  movement 
within  us  at  different  periods  of  the  day,  which  corre- 
sponds with  the  same  period  in  other  days,  and  gives  rise 
to  the  exacerbations  that  we  notice  in  hectic  and  other 
fevers.”  M.  Rostan  was  of  the  opinion  that  the  cause  of 
the  intermittence  “is  primarily  seated  in  the  fluids,  in 
the  blood  ; and  that  from  thence  it  influences,  in  a special 
manner,  the  nervous  system.” 

Post-mortem  examinations  have  heretofore  thrown 
little  or  no  light  on  the  essence  of  intermittent  fever,  and 
other  malarious  affections,  and  perhaps  never  will ; unless, 
in  the  process  of  time,  the  improvements  and  discoveries 
in  animal  chemistry  may  enable  us  to  detect  some  altered 
or  modified  condition  of  the  blood  and  nervous  matter ; 


50 


INTERMITTENT  FEVER— PATHOLOGY. 


and  the  physiologist  is  better  prepared  to  appreciate,  in 
connection  therewith,  the  peculiarities  and  properties  of 
the  functions  of  the  different  parts  of  the  nervous  sys- 
tem, both  in  health  and  disease. 

Some  believe  that  malarious  diseases  are  caused  by 
lesion  or  disease  of  the  cerebrospinal  axis , or  spinal  mar- 
row, which  they  also  consider  to  be  the  cause  of  the 
aching  in  the  back  and  limbs,  cold  sensations,  and  shiver- 
ing. In  confirmation  of  this  opinion,  they  refer  to  ten- 
derness or  pain  produced  by  pressure  on  some  portion  of 
the  dorsal  or  cervical  region.  Dr.  Malone,  of  Florida,  in 
1834,  appears  to  have  been  one  of  the  first  whose  atten- 
tion was  drawn  to  this  cause  or  complication  of  inter- 
mittent s,  and  he  believed  that  if  they  were  not  actually 
produced  by  spinal  irritation , they  were  kept  up  by  it, 
secondarily  induced.  He  refers  to  a case  (a  female)  in 
which  he  found  the  lower  part  of  the  neck  and  upper 
half  of  the  dorsal  column  tender  in  several  places  ; which 
he  cured  by  the  application  of  a mustard  cataplasm  be- 
tween the  shoulders,  just  before  the  coming  on  of  the 
chill,  and  by  the  use  of  chamomile  infusion.  Dr.  Kremer 
refers  entirely  to  the  first  dorsal  vertebra,  and  says,  if  in- 
termittent fever  is  considerable,  or  old,  or  masked,  pres- 
sure on  it,  by  giving  pain,  will  suffice  to  evince  its  ( spi- 
nal irritation)  existence.  Dr.  Grosheim  found  the  pain 
to  be  most  in  the  middle  portion  of  the  dorsal  region,  es- 
pecially in  quotidians — and  in  five  cases,  by  the  applica- 
tion of  leeches,  cured  four  of  them  without  any  other 
remedy.  Dr.  B.  Rush  Mitchell,  of  St.  Louis,  Missouri, 
considers  what  is  called  “ congestive  fever  ” toxical  apo- 
plexy of  the  cerebrospinal  system”  and  says  : We  regret 

that  we  have  not  been  able  to  substantiate  our  position  by 
dissections  which  have  been  made,  but  the  registers  of 
which  we  have  lost.”  Of  late  years,  southern  practition- 
ers have  paid  more  attention  to  the  spinal  column  in  in- 


INTERMITTENT  FEVER— PATHOLOGY. 


51 


termittents,  and  some  of  them  are  in  the  habit  of  cupping 
or  applying  locaL  applications  to  the  spine,  as  adju- 
vantia,  in  their  treatment.  I have  examined  the  spinal 
column  in  a great  many  cases  of  ague  and  fever;  and 
though  I have  seen  many  cases,  especially  recent  ones, 
in  which  1 could  discover  no  tenderness  on  pressure,  or 
in  some  so  slight  as  scarcely  to  be  perceived,  yet,  in  a 
large  majority  of  the  chronic  cases,  I have  been  able  to 
discover  one  or  more  tender  spots , principally,  or  indeed 
nearly  always,  in  the  upper  half  of  the  dorsal  region  ; 
and,  occasionally,  in  some  of  these  cases,  in  the  lower 
portion  of  the  cervical  region.  This  tenderness  of  a por- 
tion of  the  dorsal  region  may  extend  up  and  down  the 
spine  to  the  extent  of  one,  two,  three,  or  more  inches ; 
and,  in  some  cases,  after  passing  the  fingers  over  a few 
inches  where  no  tenderness  is  perceived,  another  tender 
spot  may  be  found.  I believe,  so  far  as  I can  rely  on  my 
own  observation,  that  it  is  somewhat  more  common,  and 
most  prominently  manifests  itself  in  females  of  a nervous 
temperament,  in  whom  it  is  sometimes  so  tender,  that  they 
will  shrink,  and  indeed  scream  out,  when  firm  pressure 
ikinade.  This  condition  is  frequently  observed  for  some 
time  after  the  intermittent  has  been  cured  or  disappeared  ; 
indeed,  in  many  cases,  this  spinal  affection  (as  indicated 
by  the  sensitiveness  of  the  upper  portion  of  the  dorsal 
region  particularly)  seems  to  become  much  more  promi- 
nent after  the  disappearance  of  the  fever  and  ague  ; or 
the  individual  may  be  subject  to  occasional  relapses.  I 
may  also  remark,  that  this  affection  of  the  dorsal  region, 
and  in  comparatively  few  cases  the  lower  portion  of  the 
cervical  region,  is  quite  common  among  nervous  females, 
and  not  uncommon  amongst  males,  in  the  South,  uncon- 
nected with  intermittent  fever.  This  morbid  condition  of 
the  spinal  marrow  sometimes  extends  its  influence  around 
the  sides  of  the  chest,  as  is  indicated  by  pain  {dor so- 


52 


INTERMITTENT  FEVER— TERMINATIONS. 


intercostal  neuralgia ) extending  sometimes  to  the  liver 
(, hepatalgia ) and  mammae.  I believe,  in  nervous  females, 
it  more  frequently  affects  the  lower  portion  of  the  left 
mammse  than  the  right,  often  exciting  in  them  needless 
fears  that  it  is  the  incipient  stage  of  cancer,  especially 
if  some  of  the  mammary  glands  should  be  rather  sensitive 
or  sore  on  pressure.  These  pains  about  the  chest,  to- 
gether with  a more  or  less  pallid  appearance,  also  often 
induce  them  to  believe  that  they  are  taking  phthisis  pul- 
monalis  (consumption);  or,  if  it  extends  to  the  liver 
(hepatalgia)  and  shoulder,  it  is  too  frequently  regarded, 
even  by  physicians,  as  disease  of  the  liver,  and  the  patient 
is  kept  under  the  influence  of  calomel  and  blue  mass  for 
months,  and  even  years,  till  his  or  her  health  becomes 
more  and  more  imperfect ; and  if  this  mercurial  practice 
(which  I regret  is  too  often  practiced,  to  the  destruction 
of  many  valuable  lives)  is  persisted  in,  organic  diseases 
are  induced,  and  the  unfortunate  sufferer  is  doomed  to 
lead  a more  or  less  protracted  existence,  till  consumption, 
dropsy,  or  some  other  form  of  disease,  closes  his  earthly 
career.  Perhaps  females  are  somewhat  more  frequently 
sufferers  in  these  respects  than  males,  but  it  is  not  of  very 
uncommon  occurrence  among  the  latter.  I will  defer  the 
further  consideration  of  this  subject  till  I come  to  speak 
of  it  specially. 

Terminations  of  Intermittent  Fever. — Perhaps  or- 
dinary intermittents  very  rarely,  if  ever,  primarily  produce 
death;  they  may,  however,  assume  the  remittent  or  con- 
gestive form,  and  produce  this  result.  Dr.  Eberle  says 
he  has  seen  death  occur  in  two  cases  of  simple  and  mild 
intermittent ; but  this  is  not  easy  to  reconcile;  for  if  they 
produced  symptoms  of  apoplexy  and  death  in  the  cold 
stage , I should  think  they  were  not  very  11  simple  and 
mild”  but  were  perhaps  what  is  now  termed  “ congestive 


INTERMITTENT  FEVER— TERMINATIONS. 


53 


fever.''1  He  says : “ The  violent  internal  congestions 
which  occur  during  the  cold  stage,  are  well  calculated  to 
produce  cerebral  oppression  and  apoplexy.”  I have 
never  known  a case  of  pure  uncomplicated  intermittent 
fever  to  terminate  fatally. 

This  form  of  disease  often  produces  enlargements  of 
the  spleen  and  other  visceral  affections,  but  these  usually 
yield  to  the  remedies  for  the  primary  disease,  or  get  w7ell 
of  themselves  after  the  primary  affection  has  been  cured, 
especially  if  it  has  only  been  of  short  duration;  but  if 
more  protracted,  there  are  frequent  exceptions,  especially 
with  regard  to  the  spleen.  This  viscus  may  continue 
enlarged  for  a long  time  after  the  original  disease  has  been 
cured  ; indeed,  it  is  often  neglected  till  it  becomes  per- 
manently enlarged  or  hypertrophied,  and  in  some  cases 
indurated  or  serni-ossified ; cachexia  (a  pale  tallowish 
appearance),  nervous  sympathies,  or  nervous  disorders  are 
produced,  especially  on  the  left  side  of  the  thorax  and 
corresponding  portion  of  the  spine,  left  shoulder,  neck, 
and  head.  Sympathies  also  exist  between  it  (spleen)  and 
the  stomach,  loins,  and  womb  ; and  the  liver  and  kidneys 
may  be  implicated.  These  morbid  conditions  gradually 
steal  upon  the  health  of  the  individual, ' till  debility, 
prostration,  dropsy,  and,  in  females,  derangement  of  the 
menstrual  functions,  and,  finally,  if  relief  is  not  obtained, 
death  closes  the  scene.  Besides  the  morbid  conditions 
of  the  spleen  above  noticed,  if  intermittent  fever  is  suf- 
fered to  continue  for  a long  time,  it  is  apt  to  produce 
other  visceral  diseases  and  conditions  which  may  be  re- 
garded as  sequelae  ; as,  enlargement,  induration,  &c.,  of 
the  liver  ; diseases  of  the  heart,  stomach  ; cachexia,  ane- 
mia, or  chlorosis,  and  derangements  of  the  catamenial 
functions;  anasarca,  hydrothorax,  ascites,  hydrocele, 
chronic  bronchitis,  phthisis,  etc.  etc.,  and  various  neu- 
ralgic affections. 


54  INTERMITTENT  FEVER— DISLOCATION  OF  SPLEEN,  ETC. 

Dr.  Walter  Teller,  Medical  Superintendent  of  the 
Temporary  Provincial  Lunatic  Asylum,  at  Toronto 
(Canada  West),  in  his  report  from  April  1st,  1846,  to 
March  31st,  1847,  says  : “ I would  here  refer  to  the  case 
of  three  patients,  who,  previously  to  their  becoming 
insane,  had  been  laboring  under  intermittent  fever ; after 
becoming  insane,  and  during  the  early  part  of  their  resi- 
dence in  the  asylum,  no  symptom  of  that  disease  ap- 
peared. But  suspecting,  from  their  previous  history, 
that  this  disease  might  still  be  connected  with  their 
insanity,  as  the  latent  cause,  they  were  put  under  the 
proper  treatment  for  intermittent  fever.  The  insanity 
began  to  decline,  and,  with  its  gradual  disappearance, 
the  original  disease  again  manifested  itself  in  the  usual 
symptoms.  Ultimately,  complete  restoration  to  health  of 
both  body  and  mind  was  effected.” 

Dislocation  of  the  Spleen. — So  far  as  I am  aware, 
dislocation  of  the  spleen  has  entirely  escaped  the  atten- 
tion of  almost  all  medical  writers, — and  from  this  fact, 
it  would  seem  reasonable  to  suppose  that  it  is  of  very 
rare  occurrence;  indeed,  I believe  that  there  are  but  few 
physicians  and  authors  who  are  aware  that  such  a thing 
is  possible.  Several  years  ago,  a case  of  enlargement  and 
dislocation  of  the  spleen,  in  a young  lady,  came  under  my 
professional  care.  She  had  dysmenorrhoea,  and  the  en- 
largement and  dislocation  were  principally  induced  by  the 
perturbations  of  the  system  and  congestion  during  very 
extremely  painful  catamenial  epochs.  By  protracted 
treatment  the  dysmenorrhoea  was  relieved,  the  spleen 
reduced  nearly  to  its  natural  size,  appearing  to  assume 
almost  its  natural  position,  and  seemed  to  have  become 
attached,  apparently  by  subacute  inflammation,  to  the 
surrounding  parts.  Her  health  was  now  good ; but  in 
the  latter  part  of  November,  1847,  from  exposure,  and 


INTERMITTENT  FEVER— DISLOCATION  OF  SPLEEN,  ETC.  55 

riding  in  the  country  on  a limping  horse,  during  the 
catamenial  period,  inflammation  of  the  caecum  or  perityph- 
litis, was  induced,  and  ccecal  abscess  ensued ; the  latter  ob- 
tained egress  via  the  vagina ; and  in  consequence  of  the 
most  violent  and  oft  repeated  paroxysms  of  suffering  and. 
congestions,  the  spleen  became  again  enlarged  and  dislo- 
cated, and  she  has  suffered  a great  deal  ever  since;  till 
recently  (now  December,  184S)  her  spleen  is  improving, 
and  her  general  health  getting  better  again.  She  suffered 
much  from  nervous  pains  in  the  spleen,  left  side  of  the 
thorax,  extending  to  the  left  mammae;  spine,  shoulder, 
neck,  head,  heart,  stomach,  matrix,  kidneys ; the  ccecal 
abscess  induced  pains  in  the  right  lower  limb,  on  the  lower 
and  right  side  of  the  loins,  and  upper  portion  of  sacral 
region,  in  the  matrix,  right  side,  etc.  She  was  also  much 
troubled  with  eructations  and  singultus.  The  spleen  was 
so  much  enlarged  (being  larger  sometimes  than  at  others) 
as  to  almost  fill  one  side  of  the  abdomen,  sometimes  oc- 
cupying the  right  side,  at  others  pressing  on  the  brim  of 
the  pelvis  and  fundus  of  the  matrix,  but  it  was  most 
commonly  kept  on  the  left  side  by  pressure,  and,  when 
in  bed,  by  lying  on  the  left  side,  with  the  hips  elevated.* 
About  the  last  of  December,  1848,  the  abscess  healed. 

Since  writing  the  above  (now  May,  1849,)  I am  grati- 
fied to  learn  that  the  dislocated  spleen  is  again  nearly 
reduced  to  its  natural  size,  and  has  almost  assumed  its 
normal  position,  being  lower  than  natural ; and  that  the 
dysmenorrhoea  is  almost  entirely  well — the  result  of  pro- 
tracted, and,  as  the  result  has  proved,  proper  treatment. 

In  the  latter  part  of  September  last,  another  case  of 
dislocation  of  the  spleen,  with  induration  of  this  viscus, 

* In  a conversation  Iliad  with  H.  H.  Parker,  M.  Di_(May  31st,  1849),  of 
Brandon,  Mississippi,  he  informed  me  that  lie  had  seen  two  cases  of  dislo- 
cated spleen,  both  being  enlarged,  and  one  indurated.  The  subjects  were 
females. 


56  INTERMITTENT  FEVER— DISLOCATION  OF  SPLEEN,  ETC. 

came  under  my  professional  attention.  The  subject  of 
it  is  a lady,  who  suffered  some  four  years  ago  with  inter- 
mittent fever,  and  also  occasionally  since.  The  spleen 
feels  almost  as  hard  as  bone,  is  increased  in  length,  some- 
what in  breadth,  and  very  little,  if  any,  in  thickness.  Its 
notched  edges  can  be  as  distinctly  felt,  when  its  position 
is  favorable,  as  the  cartilages  of  the  ribs  on  either  side  of 
the  epigastrium.  It  rolls  about  in  the  abdomen,  either  on 
the  left  or  right  side;,  sometimes  resting  on  the  brim  of 
the  pelvis  and  pressing  on  the  fundus  of  the  womb. 
When  I first  saw  her  she  wTas  very  low  in  health,  subject 
to  occasional  attacks  of  ague  and  fever,  of  a pale,  leuco- 
phlegmatic  appearance,  very  much  enfeebled  and  pros- 
trated, suffering  very  much  from  nervous  pains  in  the 
spleen,  left  side  of  the  thorax,  extending  to  left  mammae, 
spine,  shoulder,  neck,  head,  heart  (occasionally  palpita- 
tions), stomach,  loins,  womb.  The  liver  was  somewhat 
enlarged  and  indurated,  and  painful  on  pressure.  Cata- 
menia irregular  and  scanty  ; leucorrhqea  present.  I spoke 
guardedly  encouraging  to  her,  that  she  must  have  pa- 
tience to  persevere  in  a protracted  treatment,  but  gave  an 
unfavorable  prognosis  to  her  husband.  Up  to  this  time 
(December  16th)  she  has,  under  treatment,  improved 
much  beyond  my  expectations;  yet,  assuredly,  perfect 
health  cannot  be  expected  so  long  as  the  dislocated  spleen 
remains  in  this  situation.  An  interesting  question  might 
here  arise  as  to  the  propriety  of  extirpating  this  viscus, 
which  is  not  essential  to  life.  The  danger  of  producing 
peritoneal  inflammation,  appears  to  be  the  principal  ob- 
jection. In  reply  to  a letter  which  I recently  wrote  to 
Professor  Dunglison  on  this  subject,  he  says  (Philadel- 
phia, Oct.  28th,  1848):  * * * “In  regard 

to  the  general  question,  as  to  the  propriety  of  removing 
the  spleen,  I should  have  little  hesitation  in  stating  my 
opinion  in  the  affirmative;”  then,  after  referring  to  its 


INTERMITTENT  FEVER— DISLOCATION  OF  SPLEEN,  ETC.  57 

performance  on  animals,  which  we  will  presently  notice, 
says:  “And  they  confirm  the  idea  so  ably  urged  by  an 
old  friend  of  mine,  Dr.  Blundell,  of  London,  that  there 
is  not  as  much  danger  from  peritoneal  inflammation  in 
operations  implicating  that  membrane  as  has  generally 
been  imagined.  The  history  of  ovariotomy  has  confirmed 
his  position.  Still,  splenotomy  on  man  must  be  a serious 
and  most  dangerous  operation,  and  cases  must  be  rare 
where  it  is  indispensable,  and,  therefore,  justifiable.” 

In  his  work  on  Physiology,  after  noticing  the  various 
opinions  as  regards  the  functions  or  uses  of  the  spleen, 
he  remarks,  that  “ It  is  hard  to  say  which  of  these  specu- 
lations is  the  most  ingenious.  None  can  satisfy  the  ju- 
dicious physiologist,  especially  when  he  considers  the 
comparative  impunity  consequent  on  extirpation  of  the 
organ.  This  was  an  operation  performed  at  an  early 
period.  Pliny  affirms  that  it  was  practiced  on  runners, 
to  render  them  more  swift.  From  animals  the  spleen 
has  been  repeatedly  removed,  and  although  many  of  these 
have  died  in  consequence  of  the  operation,  several  have 
recovered.  Adelon  refers  to  the  case  of  a man  who  was 
wounded  by  a knife  under  the  last  false  rib  of  the  left 
side.  Surgical  attendance  was  not  had  until  twelve 
hours  afterwards,  and  as  the  spleen  had  issued  at  the 
wound,  and  was  much  altered,  it  was  considered  neces- 
sary to  extirpate  it.  The  vessels  were  tied  ; the  man  got 
well  in  less  than  two  months,  and  has  ever  since  enjoyed 
good  health.  Sir  Charles  Bell  asserts,  that  an  old  pupil 
had  given  him  an  account  of  his  having  cut  off  the 
spleen  in  a native  of  South  America.  The  spleen  had 
escaped  through  a wound,  and  had  become  gangrenous. 
Fie  could  observe  no  effect  to  result  from  the  extirpation. 
T.  Chapman,  Esq.,  of  Pumeah,  in  India,  has  related  a 
case  of  excision  of  a portion  of  the  spleen,  by  Dr.  Mac- 
donald, of  that  station.  A native,  about  thirty  years  of 
5 


58  INTERMITTENT  FEVER— DISLOCATION  OF  SPLEEN,  ETC. 

age,  was  gored  in  the  abdomen  by  a buffalo,  and  through 
the  wound,  which  was  about  three  inches  in  length,  a 
portion  of  the  spleen  protruded.  Six  days  afterwards, 
the  man  sought  advice  from  Dr.  Macdonald,  who  removed 
the  spleen  with  the  knife,  and  the  patient  rapidly  re- 
covered. 

“Dr.  O’Brien,  in  an  inaugural  dissertation,  published  at 
Edinburgh,  in  1818,  refers  to  a case  which  fell  under  his 
own  management.  The  man  was  a native  of  Mexico ; 
the  spleen  lay  out,  owing  to  a wound  of  the  abdomen,  for 
two  days  before  the  surgeon  was  applied  to.  The  bleed- 
ing was  profuse ; the  vessels  and  other  connections  were 
secured  by  ligature,  and  the  spleen  separated  completely 
on  the  twentieth  day  of  the  wound.  On  the  forty-fifth 
day,  the  man  was  discharged  from  the  hospital,  cured ; 
and  he  remarked  to  some  one,  about  this  time,  that  ‘ he 
felt  as  well  as  ever  he  did  in  his  life.’ 

“ Dupuytren  extirpated  the  spleen  of  forty  dogs  on  the 
same  day,  without  tying  any  vessel,  but  merely  stitching 
up  the  wound  of  the  abdomen ; yet  no  herporrhage  su- 
pervened. In  the  first  eight  days,  half  the  dogs  operated 
on,  died  of  inflammation  of  the  abdominal  viscera  induced 
by  the  operation,  as  was  proved  by  dissection.  The  other 
twenty  got  well  without  any  accident,  at  the  end  of  three 
weeks  at  the  farthest.  At  first,  they  manifested  a vora- 
cious appetite,  but  it  soon  resumed  its  natural  standard. 

“ The  experiments  which  have  been  made  on  animals 
by  removing  the  spleen,  have  led  to  discordant  results. 
Malpighi  says,  that  the  operation  was  followed  by  in- 
creased secretion  of  urine  ; Dumas,  that  the  animals  had 
afterwards  a voracious  appetite  ; Mead  and  Mayer,  that 
digestion  was  impaired,  that  the  evacuations  were  more 
liquid,  and  the  bile  more  watery  ; Tiedemann  and  Gme- 
lin,  that  the  chyle  appeared  more  transparent  and  devoid 
of  clot;  Professor  Coleman,  that  the  dogs,  the  subjects  of 


INTERMITTENT  FEVER— DISLOCATION  OF  SPLEEN,  ETC.  59 


the  experiment,  were  fat  and  indolent.  A dog-,  whose 
spleen  was  removed  by  Mr.  Mayo,  became,  on  recovering 
from  the  wound,  fatter  than  before ; in  a year’s  time  it 
had  returned  to  its  former  condition,  and  no  difference 
was  observed  in  its  appearance  or  habits  from  those  of 
other  dogs.  Similar  results  followed  the  experiments  of 
Dr.  Blundell,  Mr.  Dobson,  and  Mr.  Eagle;  and  the  last 
gentleman  states,  that  an  offer  had  been  made  him  of  a 
‘ smart  sum  of  money,’  by  a dealer  in  Leadenhall  Market, 
if  he  would  tell  him  his  method  of  fattening  animals.” 

As  before  remarked,  it  is  manifestly  not  essential  to  life. 
Dulaurens,  Keiohring,  Baillie,  and  others,  refer  to  cases 
in  which  the  spleen  has  been  absent  in  man,  without  any 
apparent  derangement  of  the  functions.  Dr.  R.  Lebby 
records,  in  the  Southern  Journal  of  Medicine  and  Phar- 
macy (Sept.  1846),  a case  of  entire  absence  of  the  spleen. 
Another  case  is  recorded  by  Dr.  Meinhard,  of  St.  Peters- 
burg!], in  a German  Journal. 

In  concluding  this  part  of  the  subject,  I will  notice 
two  other  cases  of  dislocation  of  the  spleen.  Professor 
Dunglison  records  a case,  which  occurred  in  a lady,  in 
his  Practice  of  Medicine , Vol.  I.,  pages  554-5.  He  ob- 
serves : “On  examining  the  right  side  of  the  abdomen, 
in  which  pain  had  been  experienced,  especially  on  change 
of  posture,  a large  tumor  was  found  extending  from  the 
hypochondriac  region  as  far  as  the  pelvis.  The  umbilical 
margin  of  this  tumor  could  be  felt  distinctly  lobated,  as 
if  it  were  shaped  like  the  cactus.  The  tumor  was  per- 
ceptible in  some  positions  of  the  patient  more  than  in 
others,  evidently  changing  its  seat  in  the  abdomen.”  It 
appears  that  this  case  was  brought  on  by  suffering  from 
malarious  disease  in  the  State  of  Virginia,  and  was  mis- 
taken by  the  professor  for  enlargement  or  tumor  of  the 
right  kidney.  But  he  says  : “ On  opening  the  abdomen, 
the  tumor  of  the  right  side  was  found  to  be  an  enlarged 

o o 


60  INTERMITTENT  FEVER— DISLOCATION  OF  SPLEEN,  ETC. 

spleen,  which  had  broken  away  from  its  attachments,  and 
was  resting  with  its  convex  surface  on  the  brim  of  the 
pelvis,  the  lower  extremity  of  the  organ  being  turned  up 
so  as  to  reach  the  lumbar  region.  It  was  suspended  by 
its  peritoneal  and  vascular  attachments,  and  could  be 
moved  freely  in  any  direction.”  She  was  pregnant,  and 
her  confinement  was  somewhat  premature  ; after  delivery, 
she  gradually  sunk,  until  the  period  of  her  dissolution. 
Some  years  previously,  in  a fall  from  a horse,  she  had 
injured  the  right  lumbar  region.  For  further  particulars 
in  relation  to  this  case  I refer  to  his  work,  as  there  were 
other  complications  of  a serious  nature. 

M.  Bozzi,  in  the  Gaz.  Med.  de  Milan,  reports  a case  of 
descent  of  the  spleen  into  the  pelvis,  with  symptoms  of  sub- 
acute peritonitis  and  of  intestinal  strangulation.  The 
subject  of  it  was  a female,  27  years  of  age,  with  curved 
spine,  in  the  third  or  fourth  month  of  pregnancy.  From 
the  commencement  of  utero-gestation,  she  had  been  daily 
affected  with  vomiting,  and,  at  the  period  mentioned, 
symptoms  of  subacute  peritonitis  and  intestinal  strangu- 
lation manifested  themselves,  under  which,  in  three  days, 
she  succumbed.  On  post-mortem  examination,  the  spleen 
was  found  above  the  right  iliac  region,  greatly  enlarged, 
weighing  six  pounds,  of  a black  color,  and  resting  in  part 
on  the  uterus  and  in  part  on  the  lower  portion  of  the  ilium 
and  the  ccecum,  which  were  very  much  injected.  The 
cord  of  splenic  vessels  was  twice  twisted  on  itself,  by 
which  the  return  of  blood  by  the  veins  was  impeded,  and 
which  was  the  cause  of  the  great  size  acquired  by  this 
viscus.  The  peritoneum  was  injected  principal^  at  the 
points  at  which  the  spleen  pressed.  Nothing  was  ob- 
served abnormal  in  the  interior  of  the  intestines.  (See 
Amer.  Journ.,  1847.) 

I am  inclined  to  believe  that  dislocation  of  the  spleen 
occurs  more  frequently  than  is  generally  imagined ; as 


INTERMITTENT  FEVER— PROGNOSIS. 


61 


practitioners  generally  may  not  be  careful  enough  in  their 
examinations  to  ascertain  its  existence,  and  as  the  greater 
portion  of  the  works  on  the  practice  of  medicine  do  not 
speak  of  it,  perhaps  there  are  but  few  physicians  who  are 
aware  that  such  a thing  is  possible.  The  second  case, 
which  I noticed  above,  for  the  greater  portion  of  the  last 
four  years  was  under  the  care  of  several  physicians, 
either  alternately  or  conjointly,  and,  so  far  as  I am  aware, 
they  had  never  detected  it. 

Prognosis  in  Intermittent  Fever. — Intermittent 
fever  is  one  of  the  mildest  and  most  manageable  forms 
of  disease  with  which  we  are  acquainted  ; yet,  when 
neglected  and  suffered  to  run  on,  it  may,  and  often  does, 
more  especially  in  the  poorer  classes,  produce  visceral 
and  other  affections,  which  have  already  been  noticed, 
which  may  be  protracted  and  difficult  to  cure  ; or  these 
secondary  affections,  especially  if  not  properly  attended 
to  in  time,  may  become  more  severe,  the  general  health 
more  and  more  impaired,  till  ultimately  death  results. 
Professor  Dickson,  formerly  of  Charleston,  now  of  New 
York,  says : — 

“The  general  prognosis  in  intermittent  fevers  is  favor- 
ably, with  some  allowance  for  their  tendency  in  all  sea- 
sons and  climates  to  obstinate  protraction,  and  in  hot  and 
moist  climates  to  malignant  violence.  Vernal  intermit- 
ten ts  are  everywhere  more  curable  than  the  autumnal : 
they  are  for  the  most  part  easily  manageable,  yet  not 
without  some  risk  both  of  immediate  and  ultimate  ill 
effects.”  Vernal  intermittents  are  generally  so  mild  as 
to  have  given  rise  to  the  old  saying,  that — 

“ An  ague  in  the  Spring, 

Is  physic  for  a king.” 

“ It  was  supposed  to  act  as  ‘ physic’  by  expelling  mor- 
bific matters,  which,  without  its  intervention,  might  have 


62  INTERMITTENT  FEVER— POST-MORTEM  APPEARANCES. 

been  the  source  of  more  serious  mischief.”  ( Dunglison ■ ) 
It  is  needless  to  say  this  opinion  was  erroneous.  Inter- 
mittents  should  always  be  avoided  if  possible. 

“ Particular  'prognosis. — The  favorable  symptoms  are. 
ready  solution  of  a paroxysm  by  sweating,  and  complete- 
ness of  the  apyrexia ; entire  freedom  from  local  ailment 
during  the  interval;  postponement  of  the  period  of  ac- 
cess ; and  diminution  of  the  violence  of  the  invasion. 
On  the  other  hand,  an  imperfect  apyrexia ; the  pertina- 
city of  some  of  the  local  pains  brought  on  by  the  pa- 
roxysm ; anticipation  of  the  time  of  approach  ; intensity 
of  cold  stage,  and  other  symptoms  of  congestion ; violence 
of  determination  to  important  organs,  in  the  hot  stage, 
as  to  the  head  and  stomach,  are  unfavorable  signs.” 
(Dickson.) 

Post-mortem  Appearances. — Dr.  John  P.  Harrison, 
in  the  'Transyloania  Journal  of  Medicine , Yol.  II.,  pages 
424-5,  reports  the  following  case,  which  occurred  in  the 
Louisville  Hospital.  “ Matthew  Revel,  native  of  Ireland, 
aged  22  years,  came  under  my  care  April  11th,  1827. 
He  has  been  sick  seven  weeks  with  ague  and  fever. 
There  is  ascites,  with  anasarca  of  the  face  and  feet ; he 
cannot  lie  on  the  left  side  ; spleen  much  enlarged  ; has 
diarrhoea,  with  loss  of  appetite ; pulse  moderately  full  and 
strong.  He  was  purged  with  cream  of  tartar  and  jalap ; 
had  calomel  given  as  an  alterant.  After  he  had  been  in 
the  hospital  several  days,  discovered,  in  examining  his 
thorax,  some  distinct  evidences  of  hydrothorax ; has  now 
some  cough.  He  was  purged,  blistered,  took  calomel, 
digitalis,  squills,  and  cream  of  tartar,  alternately,  but  no 
visible  amendment  resulted  from  the  treatment.  On  the 
4th  day  of  May  he  died.  Upon  examination,  a few  hours 
after  death,  the  following  appearances  of  disease  were 
seen.  The  abdominal  cavity  contained  a quart  of  water, 


INTERMITTENT  FEVER— PATHOLOGY— BLOOD. 


63 


and  more  than  a pint  of  thick,  gelatinous  substance,  of 
the  consistence  of  paste,  or  starch  as  prepared  for  starch- 
ing linen : the  peritoneum  was  thickened  generally ; the 
colon  and  stomach  were  adherent;  a firm  and  gelatinous 
adhesion  existed  between  the  heart  and  pericardium ; the 
lungs  were  adherent  to  the  pleura  costalis  of  both  cavi- 
ties; the  right  lung  was  partially  hepatized,  and  was  im- 
mersed in  a pint  of  serous  fluid.” 

The  Blood. — Perhaps  I may  remark,  without  submit- 
ting myself  to  the  charge  of  humorism , that  a sufficient 
knowledge  of  the  pathological  condition  of  the  blood,  in 
intermittent  fever,  as  well  as  other  diseases,  compared 
with  its  normal  or  healthy  condition ; together  with  a 
proper  knowledge  of  the  properties  and  functions  of  the 
nervous  system , both  in  health  and  disease,  and  the  rela- 
tions these  sustain  respectively  to  each  other , might  en- 
able us  to  form  a more  rational  therapeutics.  But  this 
desideratum,  so  difficult  to  obtain,  being  abstruse  and 
surrounded  with  difficulties,  which  will  require  a great 
deal  of  patient  research  and  minute  investigations  by  the 
most  devoted  and  ablest  chemists,  pathologists,  and  phy- 
siologists, will  perhaps  be  retarded  in  its  progress  by  some 
of  the  most  prominent  men  in  the  medical  world  throw- 
ing the  weight  of  their  influence  against  them, — prefer- 
ring a shorter  (empirical)  way  of  treating  diseases.  It 
may  be  said  that  this  department  of  medicine  is  just  be- 
ginning to  dawn  ; and  though  some  are  now  and  then.led 
astray,  as  might  be  expected  in  the  infancy  of  this  de- 
partment, yet,  it  is  to  be  hoped,  that,  step  by  step,  facts, 
and  additional  facts,  will  be  appreciated  and  combined ; 
analysis  lead  to  synthesis,  and,  ultimately,  that  a well- 
understood,  rational  therapeutics  will  be  established.  Of 
course,  in  connection  with  this  subject,  the  properties 
and  modus  operandi  of  the  different  articles  of  the  ma - 


64 


INTERMITTENT  FEVER— PATHOLOGY— BLOOD. 


ieria  medica , in  relation  to  each  condition  respectively, 
are  to  be  considered.  May  unfading  laurels  crown  the 
brows  of  those  who  devote  themselves  indefeasibly,  assi- 
duously, and  indefatigably,  to  these  investigations ! 

The  appearance  of  the  blood  in  intermittent  fever, 
when  drawn,  differs  in  different  cases,  owing  to  the  tem- 
perament of  the  patient,  the  inflammatory  nature,  com- 
plications, acute  or  chronic  form  of  the  disease,  etc.  etc. 
It  is  generally  of  a dark  color,  and  more  consistent  than 
natural.  In  those  of  a sanguine  temperament,  and  in 
the  acute  stage  of  the  inflammatory  variety,  it  will  pre- 
sent a buffy  appearance  and  firm  clot.  In  the  chronic 
form  of  ague  and  fever,  I believe  the  blood  is  usually  of 
a paler  appearance,  with  a predominance  of  serum ; and 
in  some  cases  the  surface  presenting  a greenish  hue.  In 
splenic  cachexia,  Dr.  Twining  says,  the  blood  varies  much 
in  appearance;  “sometimes  it  coagulates  imperfectly, 
and  no  serum  is  separated ; in  others,  the  cruor  is  black 
and  soft,  and,  after  being  exposed  to  the  air,  its  surface 
does  not  generally  assume  that  more  florid  color  which 
we  observe  on  the  top  of  a coagulum  of  blood  drawn 
from  the  vein  of  a healthy  person ; and  it  seldom  exhibits 
a buffy  coat,  except  when  ardent  pyrexia  is  present,  or 
where  the  disease  is  attended  with  acute  pain  in  the  side. 
The  serum,  when  heated,  coagulates  as  firmly  as  that  of 
a healthy  person,  but  the  coagulum  is  more  friable  and 
less  tough,  and  it  frequently  has  a slightly  yellowish  ap- 
pearance ; sometimes  it  has  a greenish  color.” 

Drs.  Leonard  and  Foley,  it  appears,  examined  the 
blood  in  sixty-seven  cases  of  intermittent  fever,  and  “ con- 
stantly found  that,  in  the  incipient  stages  of  the  disorder, 
the  fibrin  of  the  blood  was  undiminished,  but  that  its 
quantity  fell  under  the  influence  of  long  duration  or  re- 
lapses of  the  malady.  The  red  corpuscles,  on  the  con- 
trary, are  almost  invariably  lowered  in  quantity,  and  the 


INTERMITTENT  FEVER— PATHOLOGY— BLOOD. 


65 


albumen  of  the  serum,  in  particular,  undergoes  a marked 
diminution.” 

In  concluding  this  part  of  the  subject,  I will  refer  to 
the  analysis  of  Charles  Frick,  M.  D.,  of  Baltimore,  in 
relation  to  the  relative  proportioiis  of  the  different  organic 
and  inorganic  elements  of  the  blood,  in 

“ Remittent  and  Intermittent  Fever. — In  the  following 
table,  the  first  five  cases  are  of  remittent,  and  the  re- 
mainder of  intermittent  fever.  Two  are  of  the  congestive 
form,  one.  remittent,  No.  1,  and  the  other  intermittent, 
No.  7.  In  studying  the  proportion  of  fibrin  in  these 
cases,  it  will  be  found  that,  in  four  of  those  classed  as 
remittent  fever,  this  element  is  above  the  average  stand- 
ard,  the  exception  occurring  in  a patient,  the  duration 
of  whose  disease  had  been  three  weeks,  and  in  whom  all 
the  elements  of  the  blood,  except  the  chlorides  and  the 
phosphates,  were  below  their  natural  standard;  while  in 
five  of  the  cases  of  intermittent  fever  out  of  the  seven,  it 
is  below  the  average  quantity;  No.  10,  one  of  the  excep- 
tions, being  complicated  with  ascites,  and  oedema  of  the 
lower  extremities,  coming  on  as  an  acute  affection,  and 
being  preceded  by  a chill ; and  the  other  being  compli- 
cated with  a pneumonia  at  the  summit  of  the  lung.  It 
has  been  suggested,  that  the  difference  between  these  two 
fevers  consists  in  the  first  having  an  acute  gastro-duode- 
nites  superadded  to  the  second,  thereby  producing  the 
gastric  symptoms  so  common  to  the  one,  and  wholly 
wanting*  in  the  other,  and  also  accounting  for  the  attend- 
ant fever,  being  of  a continued  type.  The  increase  of 
the  fibrin  in  these  cases  seems,  in  a measure,  to  substan- 
tiate this  idea.  The  globules  in  the  remittent  form,  in 
all  except  the  one  above  alluded  to,  are  increased,  as  is 

* By  referring  to  the  symptoms  of  intermittent  fever,  it  will  he  seen  that 
Dr.  F.  is  in  error  in  stating  that  gastric  symptoms  are  wholly  absent. 


66 


INTERMITTENT  FEVER— PROPHYLAXIS. 


the  case  generally  with  all  the  pyrexia.  The  changes  of 
quantity  in  the  chlorides  and  phosphates  are  found  to  be 
nearly  dependent  upon  the  particular  month  in  which 
the  examination  is  made  ; and  instead  of  being-  dimin- 
ished,  as  Stephens  has  asserted,  are,  in  reality,  somewhat 
above  the  average  in  a majority  of  the  cases,  viz.,  nine 
out  of  twelve.” 


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.179 

4.424 

.580 

October  10. 

2 

5th  day. 

217.063 

782.937 

3.814 

138.546 

74:707 

.785 

.164 

5.3S0 

1.012 

Dec.  12. 

3 

1st  w.eek. 

208.250 

791:730 

3.605 

131.916 

T'3.429 

.627 

.152 

3.9S2 

.562 

August  1 . 

4 

10th  day. 

233.500 

766.500 

3.260 

137.740 

92.500 

.762 

.223 

5.063 

.923 

October  29, 

5 

3d  week. 

146.022 

853.978 

2.813 

90.306 

52.903 

.416 

.054 

4.928 

.778 

Dec.  4. 

6 

16th  day. 

176.586 

823.432 

2.000 

97.380 

77.188 

.423 

.0S3 

5.582 

1.322 

October  31. 

7 

1st  day. 

205.310 

794.690 

1.777 

122.301 

82.766 

.524 

.223 

3.449 

.602 

August  6. 

S 

197.015 

802.985 

2.324 

124.526 

70.165 

.595 

.083 

5.332 

1.743 

August  24. 

9 

201.059 

798.941 

2.656 

125.711 

72.692 

.613 

.296 

4.356 

.208 

Nov.  12. 

10 

175.338 

824.662 

6.250 

97.222 

71.866 

.446 

.192 

3.600 

1.711 

Nov.  24. 

11 

2d  day. 

207.347 

792,653 

3.057 

129.772 

74.518 

.588 

.197 

6.396 

1.261 

Dec.  12. 

12 

6 weeks. 

1S6.192 

ip  3.80S 

4.194 

112.756 

69.242 

.569 

.169 

4.828 

.335 

January  3. 

Average. 

1 18.484 

72.447 

.5S0 

.165 

4.797 

.938 

Prophylaxis. — Common  sense  would  seem  to  suggest 

OO 

to  us  that  the  most  important  knowledge  in  relation  to  any 
disease,  is  its  prevention : “An  ounce  of  prevention  is 
worth  a pound  of  medicine.”  This  knowledge  in  relation 
to  intermittent  fever  may  be  sought  for  in  its  causes  and 
its  endemial  nature,  and  the  general  principles  of  hygiene. 
In  connection  with  these,  I am  strongly  impressed  with 
the  belief,  that  one  of  the  most  effectual  means  of  pre- 
venting malarious  and  other  diseases  is  the  cold  shower 
bath,  or  sponging  the  body  all  over  with  cold  water, 
every  morning.  A resort  to  this  means  appears,  to  those 
who  are  not  accustomed  to  it,  to  be  a considerable  task, 
and  requiring  a good  deal  of  resolution ; but,  when  once 
accustomed  to  it,  these  ideas  disappear,  and  it  even  be- 
comes a luxury  with  some. 

If  malarious  diseases  are  caused  by  disturbances,  or 


INTERMITTENT  FEVER— TREATMENT. 


67 


excessive  influence  of  general  electricity,  perhaps  much 
might  be  done  in  the  way  of  prevention,  and  even  treat- 
ment, after  they  have  occurred,  by  insulating  the  beds  on 
which  we  sleep,  by  placing  glass  or  resin  between  the 
floor  and  the  lower  end  of  the  bedposts.  M.  Pallas, 
chief  physician  of  the  French  armies  in  Algeria  (a  be- 
liever in  this  hypothesis),  in  a communication  to  the 
Academy  of  Sciences,  says,  a great  number  of  observa- 
tions have  demonstrated  to  him,  that  all  the  sick  who  have 
been  thus  insulated  have  been  cured  or  relieved  of  their 
severe  diseases,  many  of  which  had  previously  resisted 
all  known  means  of  cure. 

Of  course,  regular  habits,  moderate  exercise,  and  tem- 
perance in  all  things,  should  be  observed.  Want  of  proper 
and  sufiicient  amount  of  food,  especially  in  newly  settled 
countries,  and  amongst  the  poor,  no  doubt  renders  the 
system  more  liable  to  intermittent  and  other  malarious 
fevers. 

Treatment.  — Simple,  uncomplicated,  intermittent 
fever  is  one  of  the  most  manageable  diseases  with  which 
we  are  acquainted.  It  may  be  well  to  consider,  in  the 
following  order,  the  treatment  proper  during  the  premoni- 
tory symptoms , the  chill , rigor , or  cold  stage;  the  hot  stage; 
sweating  stage  ; the  interval  or  period  of  apyrexia;  and, 
lastly,  the  chronic  form,  complications,  and  sequela. 

As  a general  rule,  during  the  premonitory  sijmptoms, 
give  a free  dose  of  quinine  (disulphate  of  quinia,  from  6 
to  12  grains),  and  laudanum  (25  to  50  or  60  drops),  or 
sulphate  of  morphine  (^  to  \ grain),  which,  if  it  does  not 
almost,  or  entirely,  avert  the  paroxysm,  greatly  modifies 
it.  A teaspoonful  or  two  of  sulphuric  ether,  which  may 
be  taken  in  half  a glass  of  sweetened  water,  stirring  it 
briskly  immediately  before  drinking  it,  will  have  a more 
prompt  effect,  at  the  same  time  breathing  or  inhaling  the 


68  INTERMITTENT  FEVER— TREATMENT. 

ether  which  evaporates  from  the  glass ; or  some  being 
poured  on  a folded  handkerchief,  will  make  the  effect 
more  prompt  and  efficient. 

These  remarks  also  apply  to  the  cold  stage , chill, 
or  rigor.  The  quinine  and  laudanum  should  imme- 
diately be  given.  The  ether  usually  affords  great 
relief,  in  most  cases  immediately  putting  a check  to 
this  stage ; but,  if  it  is  not  given  till  towards  the 
latter  part  of  the  cold  stage,  it  is  apt  to  induce 
determination  to  the  head  in  the  hot  stage,  especially  in 
robust  and  sanguine  temperaments.  If  it  is  given 
in  the  early  part  of  the  cold  stage,  it  not  only  cuts  it 
short,  but  usually  greatly  lessens  and  modifies  the  hot 
stage.  It  is  stated  in  the  Illinois  and  Indiana  Medical 
mid  Surgical  Journal  (Oct.  and  Nov.  1847),  that  Mr.  J. 
W.  Freer,  a pupil  in  the  Chicago  Hospital,  has  employed 
ether  in  intermittent  fever,  “ with  the  most  delightful 
results.  Two  or  three  inhalations  invariably  arrested  the 
paroxysm  instantaneously , during  the  cold  stage,  brought 
on  diaphoresis,  and,  in  cases  where  there  was  no  unusual 
exertion,  the  paroxysms  had  not  returned.”  Dr.  Challe- 
ton  states,  that  he  has  uniformly  succeeded  in  curing  in- 
termittent fever,  which  appeared  in  the  neighborhood 
of  Gannat,  by  administering  half  a teaspoonful  of  sul- 
phuric ether  at  a dose,  either  on  the  occurrence  of  the 
shivering  fit,  or  at  intervals  of  four  hours,  on  the  day 
before  the  attack.  Several  physicians  in  the  neighbor- 
hood, had  also  adopted  this  mode  of  treatment  with  satis- 
factory results.* 

Either  of  the  above  plans,  the  quinine  and  laudanum, 
or  sulphuric  ether,  or  a combination  of  them,  soon  greatly 
relieves  the  distressed  condition  of  the  patient ; greatly 
modifies  the  severity  of,  and  shortens  the  cold  stage,  as 


* See  Lond.  Med.  Gaz.,  Aug.  1847  ; or  Anier.  Journ.  Med.  Sci.,  Oct.  1847. 


INTERMITTENT  FEVER— TREATMENT. 


69 


well  as  lessens  the  severity,  and  shortens  the  duration  of 
the  ensuing  hot  stage.  An  emetic  of  ipecac. , or  ipecac,  and 
lobelia,  sometimes  has  a similar  effect,  but  in  a much  less 
degree.  In  general,  however,  I consider  it  a bad  plan  to 
give  emetics,  unless  there  are  irritating  matters  in  the 
stomach,  as  undigested  food,  bile,  &c.,  which  produce 
retching  and  incomplete  vomiting;  as  they  often  tend  to 
produce  gastritis,  which  makes  the  case  more  protracted 
and  troublesome.  If  the  stomach  is  very  tender,  or 
painful  on  pressure,  emetics  should  not  be  given.  When 
it  is  thought  proper  to  administer  an  emetic,  some  half  an 
hour  after  the  emesis  has  completely  subsided,  it  is  gene- 
rally advisable  to  give  a dose  of  quinine  (5  to  10  grains) 
and  laudanum  (30  or  40  drops) ; and,  in  most  cases,  6 or 
8 grains  of  calomel,  and  as  much  rhubarb,  may  be  added 
at  the  commencement  of  the  treatment.  It  should  be 
understood,  however,  that  the  calomel  and  rhubarb  are 
only  admissible  in  those  cases  attended  with  costiveness ; 
or  at  any  rate  they  should  not  be  given  where  there  is  a 
disposition  to  looseness  or  diarrhoea. 

It  is  quite  common  to  apply  warmth  to  the  extremities, 
by  means  of  warm  rocks,  bricks,  irons,  bottles  filled  with 
hot  water,  or  ears  of  corn  just  taken  out  of  boiling 
water.  Perhaps  the  latter  is  preferable  to  the  others.  I 
do  not,  however,  place  a very  high  estimate  on  these  ad- 
juvantia,  nor  am  I very  particular  in  attending  to  them, 
unless  the  patient  desires  them,  is  feeble,  or  the  chill  pro- 
tracted. 

I have  never  resorted  to  venesection,  in  the  cold  stage 
of  inter mittents,  as  has  been  recommended  by  Drs. 
McIntosh,  Twining,  and  some  others  with  less  confidence. 

As  cold  water  is  very  much  desired  by  most  patients 
in  this  stage,  I consider  it  advisable  to  allow  them  small 
quantities,  often  repeated. 

In  those  cases  in  which  the  chill  and  fever  come  on 


70 


INTERMITTENT  FEVER— TREATMENT. 


together,  give  a dose  of  morphine,  and  pour  cold  water 
freely  over  the  head  and  neck,  and  if  the  reaction  or  the 
excitement  is  considerable,  it  should  then  be  poured  over 
the  whole  person.  This  affords  great  and  almost  imme- 
diate relief.  Sometimes,  in  athletes,  and  those  of  full, 
sanguine  temperaments,  in  which  the  excitement  is  con- 
siderable, with  determination  to  the  head,  it  may  be  ad- 
visable to  resort  to  venesection  ; but  this  may  generally 
be  dispensed  with  by  pouring  cold  water  freely  and  re- 
peatedly, first  over  the  head  and  neck,  and  then  over  the 
whole  body.  To  relieve  the  distressing  nausea  and 
vomiting  that  sometimes  attend  the  cold  stage,  laudanum 
or  paregoric  should  be  given ; for  children,  the  latter 
should  have  the  preference;  and  of  course,  the  above 
remedies  recommended  for  the  adult,  should  be  modi- 
fied so  as  to  adapt  them  to  the  different  ages  of  children  ; 
mustard,  or  wrarrn  brandy,  or  whisky  and  peppermint 
may  be  applied  over  the  stomach. 

The  Hot  Stage. — If  the  above  means  have  been  at- 
tended to  during  the  cold  stage,  the  hot  stage  is  generally 
rendered  so  mild  as  to  require  but  little  attention.  If, 
however,  the  reaction  should  be  very  great,  with  de- 
termination to  the  head,  as  indicated  by  flushed  face; 
redness  of  the  eyes  ; throbbing  of  the  carotids  ; derange- 
ment of  the  mind,  in  some  cases  amounting  to  delirium ; 
and  pain  in  the  head ; it  may  usually  be  controlled  by 
pouring  cold  water  freely,  frequently,  and  copiously,  over 
the  head  and  back  of  the  neck,  and  sponging  the  whole 
person  freely  with  cold  water.  In  the  sanguine  and  ro- 
bust, if  the  pulse  is  hard  and  bounding,  and  some  im- 
portant organ  is  likely  to  suffer  from  the  excitement, 
venesection  should  be  resorted  to  at  once.  As  before 
remarked,  however,  this  excitement  can  generally  be 


INTERMITTENT  FEVER— TREATMENT.  71 

controlled  by  pouring  cold  water  freely  over  the  head, 
neck,  and  then  over  the  whole  person. 

During  this  stage,  it  is  commonly  not  necessary  to  give 
much  medicine.  Some  cooling  diaphoretic  is  generally 
sufficient;  as,  the  common  effervescing  soda,  or  Seidlitz 
powders;  lemonade,  iced  water,  or  cold  water,  etc. 

If  the  patient  is  not  seen  till  the  development  of  the 
hot  stage,  in  addition  to  the  above  directions,  it  may  be 
necessary  to  give  a dose  of  morphine  (i  or  i grain), 
with  two  grains  of  ipecac.,  or  a teaspoonful  of  tincture 
of  lobelia,  if  the  stomach  is  not  irritable  and  disposed  to 
vomiting.  If  the  pulse  is  rather  feeble,  as  well  as  fre- 
quent, wffiich  is  not  unfrequently  the  case,  laudanum 
should  be  given,  with  a free  dose  of  quinine.  If 
the  hot  stage  should  be  protracted,  or  seem  disposed  to 
assume  the  remittent  form  of  fever,  the  quinine  and 
laudanum  should  be  given,  to  which  calomel  and  rhu- 
barb, or  some  other  aperient,  should  be  added,  if  there 
is  costiveness,  or  the  bowels  are  not  disposed  to  loose- 
ness. Small  doses  of  quinine,  as  two  or  three  grains, 
should  not  be  given  during  the  hot  stage,  as  it  adds  to 
the  excitement,  while  large  doses  act  as  sedatives  and 
tend  to  soothe ; and  this  effect  may  be  encouraged  by 
the  addition  of  morphine  and  ipecac.,  and  the  free  use  of 
cold  water  applied  externally,  together  with  the  internal 
use  of  cold  or  iced  water ; and,  in  those  violent  cases  de- 
manding it,  venesection.  If  the  skin  is  hot  and  dry,  the 
patient  oppressed  and  restless,  the  external  application  of 
cold  water,  as  above  advised,  affords,  either  alone,  or  in 
combination  with  the  other  means  above  noticed,  such 
prompt  and  decided  relief,  and  so  greatly  shortens  this 
stage,  that  it  is  surprising  that  it  is  so  seldom  resorted  to. 

Sweating  Stage.— During  this  stage,  generally  little 
or  no  treatment  is  demanded.  Light  covering,  such  as 


72 


INTERMITTENT  FEVER— TREATMENT. 


is  agreeable  to  the  feelings  of  the  patient,  and  avoiding 
cool  currents  of  air,  or  exposure  to  too  low  a temperature, 
is  advisable  ; as  exposures  of  this  kind,  or  too  great  exer- 
tions, might  bring  on  a second  chill.  Cold  drinks  should 
not  be  used  as  freely  as  before.  If  the  case  occurs  dur- 
ing the  prevalence  of  an  epidemic,  in  which  there  is  a 
great  tendency  to  assume  or  run  into  the  congestive  or 
remittent  form,  we  should  administer  quinine  at  once,  as, 
by  waiting  for  this  stage  to  pass  off,  we  might  lose  im- 
portant time ; as  it  might  soon  be  succeeded  by  a rigor  of 
the  congestive  form.  Ordinarily,  however,  this  is  not  to 
be  expected. 

Period  of  Apyrexia. — This  is  the  most  important  time 
for  arresting  the  paroxysms  of  intermittent  fever.  It  will 
generally  be  sufficient  to  administer  quinine  in  from  three 
to  five  grain  doses,  four  times  a day  ; and  it  is  usually  a 
good  plan  to  add  from  half  a grain  to  a grain  of  sulphate 
of  zinc  (white  vitriol)  to  each  dose  of  the  quinine.  To 
be  more  certain  to  avert  the  next  paroxysm,  about  two 
hours  before  the  usual  time  of  its  recurrence,  take  six  or 
eight  grains  of  quinine,  with  thirty,  forty,  or  fifty  drops 
of  laudanum.  This  is  more  especially  advisable  when 
the  chills  are  of  the  quartan  type.  This  means  almost 
invariably  prevents  the  paroxysm  which  would  ensue. 
If  the  bowels  are  not  disposed  to  be  open,  give  with  the 
first  dose  of  quinine,  five  or  six  grains  of  calomel  and 
eight  or  ten  grains  of  rhubarb,  or,  what  is  in  most  cases 
preferable,  two,  three,  or  four  pills  of  the  extract  of  the 
white  walnut,  or  butternut  ( Juglans  cinerea );  extract  of 
taxaracum  and  rhubarb ; or  the  decoction  of  black  root 
( Culver's  physic ).  If  quinine  causes  roaring  in  the  head, 
or  buzzing  in  the  ears,  the  dose  should  be  lessened  to 
three  or  four  grains.  This  is  a much  better  way,  more 
effectual,  and  less  likely  to  produce  quininism,  than  the 


INTERMITTENT  FEVER— TREATMENT. 


73 


old  habit,  and  which  is  yet  practiced  by  some,  of  giving 
one  or  two  grains  of  quinine  every  hour  or  two.  Large 
doses  of  quinine  also  tend  to  resolve  hypersemia,  conges- 
tion or  inflammation  of  important  organs,  while  small 
ones  tend  to  increase  these  local  affections.  These  con- 
ditions also  more  especially  demand  the  use  of  some  of 
the  above  cathartics ; but  they  should  not  be  given  too 
freely  nor  too  frequently.  When  more  than  one  dose  is 
required,  the  next  one  should  not  be  given  till  about 
twenty-four  hours  subsequent  to  the  administration  of 
the  first  one.  They  should  usually  be  taken  at  bed-time. 
In  cases  that  are  disposed  to  costiveness  and  protraction, 
it  may  be  necessary  to  give  them  occasionally  subse- 
quently. A favorite  remedy  with  some  practitioners,  in 
cases  of  this  kind,  is  pills  composed  of  quinine,  blue 
mass,  and  oil  of  black  pepper,  or  piperine. 

Though  calomel  and  blue  mass  may  be  of  service,  es- 
pecially when  there  is  local  inflammation  of  some  im- 
portant organ,  if  administered  with  judgment  and  care, 
yet,  I am  opposed  to  their  too  frequent  and  indiscriminate 
administration,  as  their  too  liberal  use  often  produces  a 
deleterious  influence  on  the  system,  which  is  lasting.  I 
rarely  give  more  than  one  or  two  doses  of  either  of  them, 
and  that  about  the  commencement  of  the  treatment.  If 
it  is  necessary  after  this  to  use  aperients,  I commonly 
prefer  some  of  the  others  above  mentioned.  Indeed,  in 
a very  large  majority  of  cases,  calomel  or  blue  mass 
need  not  be  given  at  all;  some  of  the  other  articles  suffi- 
cing when  one  is  indicated.  Not  only  are  calomel  and 
blue  mass  used  too  freely  and  indiscriminately,  and  often 
to  an  injurious  extent  by  some  young  practitioners,  but 
perhaps  more  generally  by  old  ones  who  received  their 
medical  education  many  years  ago,  when  calomel  was 
considered  the  great  remedy  ; and  also  by  those  who  have 
recently  arrived  from  the  North;  but  they  are  used  too 
6 


74  INTERMITTENT  FEVER— CHRONIC  FORM— TREATMENT. 


freely  and  indiscriminately  by  many  southern  practition- 
ers, as  well  as  by  many  of  the  people  themselves,  in  cer- 
tain parts  of  the  country. 

Intermittents,  in  the  more  northern  portions  of  the 
world,  are,  perhaps,  more  of  an  inflammatory  nature  than 
in  southern  latitudes,  and  require  greater  attention  to  an- 
tiphlogistic treatment. 

Some  of  the  articles  to  be  mentioned  presently,  or  here- 
after, may  be  used  instead  of  the  quinine,  and  this  should 
more  particularly  be  attended  to  in  those  cases  where 
quinine  is  known,  or  found,  to  disagree.  In  some  persons, 
it  is  apt  to  produce  unpleasant  effects  on  the  brain.  (See 
the  chronic  form  below,  and  also  Chapter  XVI.) 

Chronic  Form.— When  intermittent  fever  is  protracted, 
or  suffered  to  continue,  till  it  assumes  what  we  may  call 
the  chronic  form , the  patient  usually  becomes  more  pale, 
frequently  leaner  than  usual,  but  is  also  frequently  apt  to 
present  some  embonpoint,  is  more  or  less  bloated,  and 
frequently  of  a pale  tallowish  appearance,  and  perhaps 
anasarcous.  In  many  of  these  cases,  the  stomach  and 
system  seem  to  lose  their  ordinary  susceptibility  to  the 
influence  of  quinine ; hence,  it  becomes  necessary  to 
combine  other  remedies  with  it.  Many  persons,  who  are 
not  aware  of  this,  become  dissatisfied  with  the  quinine, 
abandon  it,  and  seek  for  other  remedies.  One  of  the  best 
combinations,  in  these  cases,  is  quinine  (4  to  6 grains), 
carbonate  of  iron  (10  or  15  grains),  and  pulverized  cap- 
sicum (cayenne  pepper,  4 grains),  which  is  to  be  taken 
(incorporated  with  molasses,  syrup,  or  wet  with  spirits) 
at  a dose.  A dose  of  this  should  be  taken  every  four 
hours,  so  as  to  take  three  or  four  doses  before  the  usual  or 
expected  time  of  the  recurrence  of  the  chill,  which  is 
almost  sure  to  avert  it ; or  what  makes  it  more  certain, 
the  addition  to  a dose,  about  two  hours  before  the  ensuing 


INTERMITTENT  FEVER— CHRONIC  FORM— TREATMENT.  75 

chili  time,  of  thirty  to  fifty  drops  of  laudanum.  The  fol- 
lowing: formula  is  also  an  excellent  combination  in  obsti- 
nate  and  protracted  cases,  and  more  particularly  adapted 
to  those  who  have  a somewhat  florid  appearance  : — 

Bt . Sulphate  of  quinine  forty  grains  ; 

Sulphate  of  zinc  twelve  grains  ; 

W ater  five  fluid  ounces  ; 

Elixir  vitriol  forty  drops. 

First  dissolve  the  quinine  in  the  water  by  the  addition 
of  the  elixir  vitriol,  or  a few  drops  of  sulphuric  acid,  then 
add  the  zinc.  Dose,  two  or  three  teaspoonfuls,  four  times 
a day  ; and,  after  the  chills  have  been  arrested,  it  should 
be  taken  four  times  the  ensuing  day  ; three  times  a dajr 
for  the  next  three  or  four  days ; then  twice  a day  for  four 
or  five  days,  to  prevent  a relapse.  If  the  chill  is  of  the 
tertian  or  quartan  type,  the  medicine  should  be  taken  four 
times  a day,  till  the  next  regular  chill  time  passes,  after 
which  it  may  be  used  less  and  less  frequently.  This 
means  not  only  tends  to  prevent  a relapse,  but  contributes 
as  a tonic,  to  restore  the  lost  vigor  and  healthful  condition 
of  the  system.  These  suggestions  should  also  be  carried 
out,  when  the  quinine,  iron,  and  pepper,  above  recom- 
mended, are  used.  In  some  cases,  after  the  chills  have 
been  arrested,  the  continued  use  of  the  above  remedies 
sometimes  disagree  with  the  stomach,  in  which  cases 
some  other  tonic  may  be  substituted ; as,  infusion  or  tinc- 
ture of  dogwood,  cherrytree,  and  poplar  bark  ; or  an  in- 
fusion or  tincture  of  the  leaves  of  the  wild  holly  ( Ilex 
opaca ),  Peruvian  barks,  quassia,  gentian,  etc.  etc. 

In  those  cases  in  which  there  is  a strong  proclivity  to 
relapse  frequently,  and  in  which  the  features  have  rather 
a florid  (which  is  more  apt  to  be  the  case  with  the  athletic 
and  sanguine  temperament)  than  a pale  tallowish  ap- 
pearance ; after  warding  off  the  paroxysms  by  the  means 
above  noticed,  it  is  sometimes  a good  plan  to  give  Fow- 


76  INTERMITTENT  FEVER— CHRONIC  FORM— TREATMENT. 

ler’s  solution,  as,  in  these  cases,  there  is  generally  some 
visceral  disease  ; the  arsenic  acting  in  a similar  manner 
to  a combination  of  quinine  and  calomel  or  blue  mass, 
curing  both  the  ague  and  fever,  and  the  visceral  affection, 
at  the  same  time.  It  may  be  given  for  a fortnight,  or 
three  weeks,  as  in  the  following  formula : — 

R.  Fowler’s  solution  three  teaspoonfuls  ; 

W ater  four  ounces  and  three  teaspoonfuls 

Laudanum  two  teaspoonfuls ; 

Creasote  ten  drops. 

/ s 

Mix,  and  shake  well  before  taking.  Dose,  one  teaspoon- 
ful three  or  four  tunes  a day.  It  may  be  necessary  to  use 
some  of  the  aperients  before  noticed,  as  occasion  may 
require,  twice  or  thrice  a week.  Of  course,  much  will 
have  to  depend  on  the  judgment  of  the  practitioner,  in 
each  individual  case,  with  regard  to  the  length  of  time 
and  the  repetition  of  these  remedies.  If  the  arsenic  has 
an  unpleasant  effect  on  the  stomach,  or  produces  its  pe- 
culiar effect  on  the  system,  as  indicated  by  swelling  of 
the  evelids  and  face,  and  a feeling  of  stiffness  in  these 
parts,  itching  of  the  skin,  tenderness  of  the  mouth,  loss 
of  appetite,  it  should  be  suspended.  It,  however,  very 
seldom  produces  these  effects,  when  given  as  above  di- 
rected. It  should  be  given  with  care  and  judgment.  I 
generally  prefer  the  following  formula  to  it. 

R . Quinine  sixty  grains  ; 

Sulphate  of  zinc  forty  grains ; 

Tincture  of  sanguinaria  Canaden.  four  ounces  ; 

W atet  one  ounce  ; 

Elixir  vitriol  sixty  drops. 

First  mix  the  tincture  of  the  puccoon  root  and  the 
water,  then  put  in  the  quinine,  shake  the  mixture,  and 
add  the  elixir  vitriol  or  a few  drops  of  sulphuric  acid,  and, 
lastly,  add  the  white  vitriol,  and  shake  the  mixture. 
Dose,  for  an  adult,  from  40  to  60  drops  three  or  four  times 


INTERMITTENT  FEVER— CHRONIC  FORM— TREATMENT.  77 


a day.  When  it  is  given  more  particularly  for  the  pur- 
pose of  preventing  a relapse,  a dose  three  times  a day 
may  suffice. 

When  intermittents  are  attended  with  diarrhoea , 
opiates,  or  opiates  and  astringents  must  be  given  to  stop 
this  profluvia.  Paregoric,  laudanum,  opium,  or  any  of 
these  combined  with  sugar  of  lead,  catechu,  krameria, 
infusion  of  oak  bark,  nutgalls,  or  other  astringents,  will 
generally,  or  perhaps  invariably,  fulfil  this  indication.  If 
the  discharges  should  be  frequent,  copious,  and  obstinate, 
a teaspoonful  of  laudanum  should  be  given  by  injection, 
mixed  with  a fluid  ounce  of  starch  or  flour  gruel,  or 
water. 

The  Cold  Douche , or  Shower  Bath. — Considering  the 
potency  of  this  means  of  curing  intermittents,  it  may  be 
considered  somewhat  surprising  that  it  is  so  seldom  re- 
sorted to  ; and  not  only  is  it  effectual  in  curing  ague  and 
fever,  but  those  nervous  affections  and  visceral  engorge- 
ments which  so  often  complicate,  attend,  or  are  the 
sequelie  of  this  disorder. 

The  cold  shower  hath , cold  dash , or,  for  those  who  are 
too  feeble  to  bear  either  of  these,  sponging  the  body  with 
cool  or  cold  water,  should  be  resorted  to  early  every 
morning,  or  at  least  some  two  or  three  hours  before  the 
time  for  the  ensuing  chill.  After  the  chills  have  been 
arrested,  this  means  should  be  resorted  to  every  morning 
for  two  or  three  weeks  afterwards,  to  prevent  relapse, 
and  to  act  as  a tonic  in  regaining  the  lost  tone  and  vigor 
of  the  system ; indeed,  it  is  advisable  to  use  it  through- 
out the  season.  This  may  be  used  alone,  or  in  con- 
junction with  the  remedies  recommended  above,  for  the 
cure  of  the  chills,  and  to  prevent  relapse,  as  well  as  to 
act  as  a tonic.  The  external  application  of  the  cold 
water  should  not  occupy  a longer  time  than  from  one  to 


78  INTERMITTENT  FEVER— CHRONIC  FORM— TREATMENT. 

two  minutes,  as  its  prolonged  application  might  have  an 
effect  contrary  to  that  which  was  intended.  Those  who 
prefer  it,  may  plunge  suddenly  into  an  adjacent  stream, 
but  they  should  immediately  leave  the  w'ater,  and  dress 
themselves. 

In  corroboration  of  some  of  the  above  statements,  I 
will  refer  to  a memoir  presented  to  the  French  Academy 
of  Sciences  by  M.  Fleury,  on  the  use  of  cold  douches  in 
the  treatment  of  intermittent  fever. 

“ He*  was  led  to  these  researches  by  the  assertion  of 
Dr.  Currie,  that  the  accessions  of  ague  might  be  prevented 
by  the  affusion  of  cold  water,  and  that,  by  its  repetition 
four  or  five  times,  the  disease  might  be  entirely  cured. 
M.  Fleury  has  employed  this  means  one  or  two  hours 
before  the  expected  paroxysm,  in  the  form  of  a general 
douche,  and  in  that  of  a local  one  to  the  region  of  the 
spleen. 

“ The  ends  attained  by  the  above  plan  he  believes  to 
be  : 1.  A shock  exerted  on  the  nervous  system,  and  on 
the  general  capillary  circulation.  2.  The  opposing  of  a 
vigorous  reaction  and  general  stimulation  of  the  surface 
to  the  cold  stage  of  the  fever.  3.  A modification  of  the 
circulation  of  the  spleen,  combating  congestion  of  that 
organ. 

“ He  has  pursued  this  treatment  in  eleven  cases  of  in- 
termittent fever.  In  seven  of  them  the  disease  was 
recent,  and  there  had  been  but  from  three  to  seventeen 
paroxysms;  quinine  had  not  been  administered  in  any 
one.  In  two  cases,  the  spleen  preserved  its  normal  size ; 
in  five,  it  was  enlarged  ; a cure  -was  effected  in  all.  In 
one,  a single  douche  sufficed  to  cut  short  the  fever. 
In  two  others,  two  affusions  were  necessary  to  do  so, 

* I take  the  above  from  the  American  Journal  of  Medical  Sciences,  Oct. 
1848.  It  may  also  be  found  in  several  other  medical  Journals. 


INTERMITTENT  FEVER— CHRONIC  FORM— TREATMENT.  79 


and  to  restore  to  the  spleen  its  natural  dimensions.  In 
the  remaining  four,  affusion  was  practiced  three  times. 

“ In  those  patients  where  two  or  three  douches  were 
used,  the  effects  produced  were  constantly  the  same. 
By  the  first  application,  the  accession  was  retarded  two 
or  three  hours;  the  rigors  less  violent  and  shorter  by 
one-half  or  five-sixths  the  time  ; the  heat  and  headache 
were  equally  lessened  ; and  the  total  duration  of  the  fit 
was  diminished  by  at  least  one-half.  Age  and  the  type 
of  the  fever  did  not  exercise  any  appreciable  influence 
over  the  effects  of  the  treatment.  Where,  however,  the 
volume  of  the  spleen  was  larger,  the  time  required  for 
the  cure  was  augmented.  Four  patients  had  suffered 
from  the  disease  for  from  two  to  eleven  months,  having 
had  several  relapses,  and  resisted  the  action  of  sulphate 
of  quinine,  and  presented  the  anaemia,  emaciation,  ano- 
rexia, etc.,  seen  in  those  who  have  been  long  affected  by 
ague.  Three  douches  were  required  in  two  of  these 
cases,  and  five  in  one  other,  to  remove  the  fever;  but 
from  eight  to  eleven  were  necessary  to  cause  the  splenic 
engorgement  and  the  cachectic  symptoms  to  disappear. 
In  one  case  the  liver  was  very  greatly  enlarged ; but  this 
condition  disappeared  by  perseverance  with  the  affusions. 

“ M.  Fleury  arrives  at  the  following  conclusions:  1. 
In  the  treatment  of  recent  intermittent  fever,  simple,  and 
with  little  or  no  engorgement  of  the  spleen,  cold  douches 
may  be  substituted  for  quinine.  2.  In  the  treatment  of 
old-standing  ague,  where  several  relapses  have  occurred, 
and  there  is  considerable  enlargement  of  the  spleen,  or  of 
the  liver,  with  a cachectic  condition,  cold  affusions  are 
to  be  preferred  to  quinine  ; for  they  cut  short  the  fever, 
restore  the  viscera  to  their  natural  volume,  and  remove 
the  cachexy  more  rapidly  and  more  safely  than  quinine ; 
the  latter,  in  large  doses,  not  unfrequently  acting  injuri- 


80 


CACHEXIA,  ETC. 


ously  upon,  the  nervous  system,  or  on  the  digestive 
organs.”  . 

When  this  cachectic  condition  attends,  I feel  assured 
that,  besides  using  the  cold  dash,  a dose  composed  of 
carbonate  of  iron,  six  or  eight  grains;  quinine,  two 
or  three  grains ; and  pulverized  capsicum,  two  or  three 
grains,  should  be  given  three  times  a day,  till  the  health 
of  the  individual  is  restored. 


CHAPTER  III. 

CACHEXIA. 

Under  this  head  may  be  considered  several  ana- 
logous affections,  presenting  respectively  some  pecu- 
liarity : as,  ancemia  proper ; hydro-poly cemia,  or  serous 
poly  cemia  ; chlorosis  ; dropsy.  In  connection  with  either 
of  these,  some  local  disease  may  be  more  manifest  than 
another,  or  several  of  the  viscera  may  be  about  equally 
affected  : amongst  these  we  may  mention  the  spleen 
(hence  called  by  Dr.  Twining  u splenic  cachexia”),  liver, 
womb , bronchia  (chronic  bronchitis),  lungs  (consump- 
tion, etc.),  heart,  stomach,  and  bowels  (frequently  atonic 
dyspepsia).  Spinal  irritation,  and  a variety  of  neuralgic 
affections,  may  also  attend. 

Notwithstanding  this  family  of  diseases,  with  some  ex- 
ceptions, is  generally  easily  managed,  yet,  for  want  of  pro- 
perly appreciating  the  nature  of  these  variously  modified 
conditions,  and  a corresponding  adaptation  of  treatment, 
malpractice,  to  a woful  and  almost  unlimited  extent,  has 
brought  no  small  amount  of  opprobrium  on  the  profes- 
sion, and  consequently  driven  hundreds  and  thousands 


CACHEXIA,  ETC. 


81 


to  seek  relief  from  quack  nostrums  (which  they  have 
used,  one  after  another,  accordingly  as  some  puffing  and 
lying  or  forged  certificate  happened  to  fall  in  their  way), 
which  usually  makes  their  condition  worse ; perhaps, 
nearly  all  of  them  contain  some  opiate,  which  gives  the 
sufiferer  temporary  relief,  and  wffiich  induces  him  to 
fancy  himself  better,  while  it  is  but  a syren  to  lead  him 
more  certainly  to  the  tomb : or  perhaps  he  is  driven  to 
homoeopathy,  a sort  of  nonsensical  refined  monomania , 
wffiich  is  practiced  (or  pretended  to  be  practiced)  on  the 
gullibility  of  the  credulous,  and  which  every  philanthro- 
pist, friend  of  science  or  humanity,  should  discounte- 
nance. Nor,  under  these  circumstances,  should  we  be 
surprised  at  the  temporary  popularity  of “ steam  doctors 
another  wide-spread  delusion  which  swept  across  our 
country  some  years  ago.  But  to  these  evils,  allopathy, 
or  eclectic  medicine,  is  indebted  to  some  extent,  for  their 
salutary  influence  in  correcting,  or  tending  to  correct, 
some  of  the  abuses  in  practice  among  the  regular  pro- 
fession. And  here  I will  remark,  with  due  deference  to 
the  intelligence  and  ability  of  northern  physicians,  with 
regard  to  the  diseases  of  their  own  climate,  that  southern 
practitioners  have  been  too  long  looking  through  northern 
spectacles,  with  regard  to  this  family  of  diseases.  I be- 
lieve it  is  almost  a universal  custom  with  a large  majority 
of  southern  practitioners,  and  the  people  generally,  when 
they  see  an  individual  affected  with  any  of  these  cachec- 
tic conditions,  to  remark  that  he  or  she,  as  the  case  may 
be,  has  uthe  liver  complaint and  conclude,  as  a matter 
of  course,  that  calomel  and  blue  mass  must  be  given,  as 
these  are  the  remedies  for  all  diseases  of  the  liver.  This 
error  has  been,  and  is  still  one  of  the  greatest  curses  to 
the  people  in  the  malarious  regions  of  the  South ; and, 
as  before  remarked,  has  brought  considerable  opprobrium 
on  the  profession,  as  such  treatment  not  only  makes  the 


82 


CACHEXIA,  ETC. 


general  condition  worse,  but  increases  the  existing  or- 
ganic affections,  as  well  as  tending  to  develop  local  dis- 
eases elsewhere ; — as,  for  instance,  if  the  spleen  or  liver 
is  primarily  affected,  the  continued  use  of  mercurial  pre- 
parations will  not  only  increase  this  organic  affection, 
but  is  almost  sure  to  induce  disease  of  the  lungs,  womb, 
heart,  stomach,  etc.  etc.,  which  become  very  stubborn, 
perhaps  incorrigible,  and  the  patient  is  doomed  to  drag 
out  a more  or  less  protracted  and  unpleasant  or  mise- 
rable existence. 

Connected  with  these  considerations,  the  abuses  by 
fashionable  dressing,  the  employment  of  ignorant  mid- 
wives, improper  mode  of  living,  and  a warm,  relaxing 
climate,  make  these  curses  tell  most  heavily  on  females, 
in  diseases  of  the  womb; — as  chronic  inflammation,  in- 
duration, and  enlargement;  prolapsus;  tumors;  inflam- 
mation or  ulceration  of  the  neck  of  the  womb,  and  leu- 
corrhoea;  disturbance  of  the  menstrual  functions;  and 
also  in  pulmonary  affections ; atonic  dyspepsia ; spinal 
irritation,  and  neuralgias  of  various  kinds.  In  many 
cases  of  chronic  ague,  which  have  lasted  for  a long  time, 
or  the  chills  may  have  disappeared,  or  recur  occasionally, 
and,  I believe,  more  especially,  if  calomel  or  blue  mass 
has  been  given  for  a long  time,  there  is  enlargement  and 
induration  of  the  spleen,  and  also  of  the  liver,  but  gene- 
rally to  a less  extent. 

Those  afflicted  with  these  cachectic  maladies,  present  a 
pale  appearance  resembling  the  color  of  tallow,  in  some 
cases  slightly  tinged  with  a yellowish  hue ; the  sclerotica, 
or  white  of  the  eye,  is  unusually  white.  They  may  be 
leaner  (anaemia)  than  natural,  or  they  may  present  a 
bloated  appearance  or  fulness  of  the  face  and  abdomen 
(serous  polyaemia),  while  their  limbs  may  be  thin  and 
flabby  ; or  there  may  be  a general  dropsical  appearance 


CACHEXIA— SEROUS  POLYJEMIA. 


83 


(anasarca) ; in  some  cases,  ascites  being  most  prominent; 
in  others,  hydrothorax,  or  hydrocele. 

In  corroboration  of  some  of  the  above  statements,  and 
for  farther  observations  on  this  subject,  I will  refer  to 
some  remarks  by  R.  E.  Little,  M.  D.,  of  Quincy,  Florida. 
He  says : “ Strangers  visiting  the  southern  States,  are 
astonished  at  the  number  of  pale  and  bloated  faces  to  be 
seen,  especially  among  children,  faces  which  attract  but 
little  notice  from  the  inhabitants  of  the  country,  so  long 
have  they  been  regarded  as  the  result  of  an  unhealthy 
location  (malarial),  or  a deranged  liver,  the  latter  being  the 
commonly  assigned  cause.  To  neither  of  the  above 
causes,  we  venture  to  assert,  are  they  to  be  attributed — 
save  in  a very  fewT  cases — an  assertion  which  we  are  as- 
sured will  be  seconded  by  a majority  of  the  well-informed 
and  observant  members  of  the  profession.*  During  our 
residence  in  Florida,  we  have  been  called  on  to  treat 
many  cases  of  what  we  have  denominated  serous  poly- 
gemia.  * * 

“ Symptoms  of  disease  are  manifested  not  only  in  the 
appearance  of  the  countenance — pale  and  bloated — but 
also  in  the  contour  of  the  body,  the  abdomen  large,  limbs 
emaciated,  and  muscles  inelastic.  The  physical  appear- 
ance of  the  patient,  to  an  experienced  eye,  indicates  the 
true  character  of  the  disease.  The  slightest  exertion 
produces  difficulty  of  breathing,  increased  action  of  the 
heart,  and  in  a very  short  time  pulsations  in  many  of  the 
larger  veins  are  perceptible,  particularly  in  those  of  the 
neck.  The  face  has  a cadaverous  appearance,  the  eyes 
lose  their  accustomed  brilliancy,  suffusion  of  the  cheeks 
rarely  appears,  and  when  it  does  it  is  circumscribed  : in 

* It  may  be  proper  to  remark,  that  this  cachectic  condition  is  not  unfre- 
quently  primary  in  certain  localities,  while  in  others  it  is  most  frequently 
the  sequelae  to  malarious  diseases. 


84 


CACHEXIA— SEROUS  POLYiEMIA. 


short,  the  intellectual  manifestations  (physically)  are  in 
a great  measure  wanting.  In  the  early  stages  of  the  dis- 
ease, the  pulse  is  usually  small  and  feeble,  occasionally 
intermittent,  but  as  the  disease  advances,  it  is  apt  to  be- 
come full,  and  convey,  when  felt  at  the  wrist,  an  idea 
that  the  finger  is  placed  on  the  femoral  instead  of  the 
radial  artery,  a phenomenon  which  disappears,  however, 
a short  time  before  dissolution.  The  appetite  is  capri- 
cious, at  one  time  ravenous  and  desiring  articles  not 
usually  esteemed  luxuries,  such  as  paper,  leaves,  and 
buds  of  trees,  pieces  of  slate,  red  clay,  &c.,  while  again 
the  stomach  revolts  at  anything  presented.  The  breath 
is  fetid,  the  bowels  loose  and  constipated  by  turns,  and 
the  discharges  of  an  ash  color.  Not  unfrequently,  before 
death,  a dropsical  accumulation  occurs  in  one  or  more  of 
the  great  cavities  of  the  body,  and  occasionally  it  is  uni- 
versal. 

“ But  the  most  remarkable  features  of  the  disease  are 
the  peculiar  sounds  given  out  by  the  larger  blood-vessels, 
both  veins  and  arteries.  Bouillaud  says,  that  if  the  ear 
be  applied  over  an  artery,  a dull  rubbing  sound  may  be 
heard ; though  feeble,  it  may  be  distinctly  detected. 
Aware  of  this  fact,  the  sounds  attendant  on  the  disease 
in  question,  when  recognized  in  one  of  the  first  patients 
which  came  under  our  care,  were  not  deemed  altogether 
unnatural,  but  subsequent  examinations  convinced  us, 
that  they  were  louder  and  longer  than  those  given  out 
during  . a state  of  health,  and  consequently  the  result  of 
disease.  In  every  case  since  treated,  stethoscopic  exami- 
nations have  been  made,  and  we  regard  such  sounds  as 
being  almost  certainly  indicative  of  the  existence  of  se- 
rous polysemia,  as  they  are  to  be  heard  very  rarely  under 
any  other  condition  either  of  the  blood-vessels  or  the 
blood  itself.  V.  S.,  a boy  fifteen  years  of  age,  a native 
of  South  Carolina,  but  for  the  last  six  3mars  a resident  of 


CACHEXIA— SEROUS  POLYjEMIA, 


85 


Florida,  presented  himself  to  us  as  the  subject  of  ‘ liver 
complaint/  His  physical  appearance  at  first  sight  indi- 
cated the  nature  of  his  disease.  A walk  of  a mile  had 
almost  completely  exhausted  him.  His  breathing  was 
hurried,  pulse  130  and  full,  the  carotids  beating  so  vio- 
lently as  to  be  visible  at  the  distance  of  twenty  or  thirty 
feet;  abdomen  large,  limbs  emaciated,  and  his  face  of  a 
cadaverous  appearance.  He  lamented  his  indisposition 
to  apply  himself  to  any  steady  employment.  A stetho- 
scope was  applied  to  the-  precordial  region ; the  bruit  de 
soufflet  was  distinctly  heard,  inexperience  leading  us  to 
imao-ine  the  existence  of  a contracted  state  of  some  of  the 
cardiac  orifices.  The  same  sound  was  heard  over  the 
course  of  the  carotid  and  femoral  arteries.  At  a subse- 
quent examination,  the  bruit  de  soufflet  failed  to  be  heard 
in  the  precordial  region,  although  it  was  still  clearly  to 
be  distinguished  in  the  arteries.  In  the  first  instance, 
the  patient  had  been  taking  exercise  on  foot:  in  the  lat- 
ter, he  had  abstained  from  exercise  for  a day  or  two.  A 
majority  of  the  cases  have  exhibited  the  same  symptoms 
in  a greater  or  less  degree,  the  rubbing  sound  disappear- 
ing gradually  as  the  health  was  restored.” 

It  may  be  proper  here  to  remark,  that  be  the  nature  of 
the  disease  whatever  it  may,  if  there  is  a diminution  in 
the  amount  of  the  globules,  this  bruit  de  soufflet  may  be 
heard  in  the  carotids.  M.  Andral  has  observed,  “ that, 
in  different  persons,  the  arterial  soufflet  does  not  ahvays 
appear  with  the  same  degree  of  depression  of  the  propor- 
tion of  globules.  He  considers,  however,  that  the  follow- 
ing rules  exist  on  this  subject.  First.  When  the  ratio 
of  globules  has  gone  below  80,  the  bruit  de  soufflet  exists 
in  the  arteries  continuously.  To  this  law  he  has  not 
seen  an  exception.  Secondly.  Wlien  the  globules  remain 
above  80,  the  bruit  de  soufflet  may  still  exhibit  itself;  but 
it  is  no  longer  constant.  It  is  still  heard,  when  the  pro- 


86 


CACHEXIA— CHLOROSIS. 


portion  of  globules  varies  between  80  and  100;  and  oc- 
casionally when  it  is  above  100.”  ( Dunglison .) 

While  speaking  of  the  sounds  afforded  by  auscultation 
of  the  blood-vessels,  I will  refer  to  the  following  remarks 
made  by  Professor  Dunglison,  when  speaking  of  chlorosis: 
“ One  of  these  has  been  termed  bruit  de  diable,  in  conse- 
quence of  its  resemblance  to  that  of  the  diable  or  hum- 
ming top  of  children.  It  is  heard  most  frequently  along 
the  carotid  and  subclavian  arteries;  at  times,  also,  in  the 
crural  arteries,  but  never  to  the  same  degree.  Commonly, 
it  is  heard  on  one  side  only.  The  bruit  de  diable  disap- 
pears immediately  on  compressing  the  artery  below  the 
part  at  which  it  is  heard;  it  disappears,  also,  on  pressing 
the  artery  forcibly  with  the  stethoscope;  and,  what  is 
surprising,  the  bruit  often  appears  and  disappears  from 
one  minute  to  another,  without  our  being  able  to  detect 
the  cause  of  these  alterations.  At  times,  the  mere  change 
of  the  patient’s  position  is  sufficient  to  effect  this.”  Dr. 
Little,  in  his  remarks  on  Serous  Polysemia  says:  “The 
loudest  sounds  are  heard  in  those  vessels  nearest  the 
centre  of  circulation,  for  instance,  in  the  subclavian  and 
carotid  arteries.  There  is  frequently  a difference  be- 
tween the  right  and  left  carotids,  the  left  giving  out  the 
loudest  sound,  which  is  capable  of  being  increased  by 
pressure  moderately  applied,  or  entirely  stopped  by  com- 
pressing the  vessels  between  the  point  where  the  ear  is 
applied  and  the  heart.  Position  also  influences  the  in- 
tensity of  the  bruit,  an  erect  posture  increasing,  a recum- 
bent diminishing  it.  It  is  always  heard  most  distinctly 
when  the  larynx  is  in  its  natural  position;  drawing  it  to 
the  opposite  side  diminishes  it,  frequently  entirely  de- 
stroys it.”  M.  Raciborski  says,  that  the  soufflement 
musical  is  more  frequent  in  thin  and  nervous  persons 
affected  with  chlorosis;  and  the  bruit  de  diable , in  the 
stouter.  The  bruit  de  diable  has  been  observed  after 


) 


CACHEXIA— CHLOROSIS.  87 

copious  blood-letting,  but  disappearing  when  the  blood 
has  regained  its  properties  by  the  use  of  tonics. 

“ From  an  analysis  of  88  cases  of  anaemia,  in  which 
there  was  a continuous  or  intermittent  sound  heard  over 
the  carotids,  M.  Andral  has  endeavored  to  establish  a 
ratio  between  the  diminution  of  the  globules,  and  the 
appearance  of  such  sound.  Of  the  88  cases,  the  soufflet 
was  continuous  in  56 ; intermittent  in  32.  Of  the  56 
cases  in  which  the  sound  represented  the  bruit  de  diable, 
in  28  the  proportion  of  globules  was  not  above  80,  and 
descended  as  low  as  21 ; in  13,  the  ratio  was  between  80 
and  100;  in  10,  it  rose  to  between  100  and  115  ; and  in 
5,  it  rose  from  115  to  125.  In  the  32  cases  in  which  the 
sound  was  intermittent,  there  were  only  3 in  which  the 
proportion  of  globules  was  below  80  (76,  77,  77);  13 
from  80  to  100;  8 from  100  to  115,  and  8 from  115  to 
126. 

“The  intensity  of  the  sound  is  generally  in  a ratio 
with  the  degree  of  diminution  of  the  globules.  In  22 
cases  of  chlorosis,  Andral  found  it  intermittent  in  8,  the 
proportion  of  globules  oscillating  between  117  and  77 ; 
continuous  in  14,  the  proportion  of  globules  varying  be- 
tween 113  and  28. 

“ When  blood  is  drawn  in  chlorosis,  it  commonly  pos- 
sesses the  qualities  referred  to  above.  It  is  thin,  light- 
colored,  and  deficient  in  red  particles.  The  clot  is  of 
less  proportion  to  the  serum  than  in  health.  To  the  de- 
ficiency of  red  particles  are  assigned  the  diminished 
temperature  of  the  surface,  the  pallor  and  waxy  appear- 
ance, as  well  as  the  want  of  color  in  the  catamenia,  and 
the  pale  stain,  which  the  blood,  in  cases  of  epistaxis, 
leaves  upon  linen. 

“ Some  analyses  have  been  made  of  chlorotic  blood. 
In  two  well-marked  cases,  referred  to  by  Dr.  Babington, 
it  contained  871  and  852  parts  in  1000  of  water,  instead 


88 


CACHEXIA— SEROUS  POLY^MIA. 


of  780,  the  healthy  standard  ; and  the  coloring  matter 
amounted  to  48.7  and  52  respectively,  instead  of  127. 
The  albumen  and  salts  were  in  the  usual  proportion. 
In  other  cases,  which  occurred  to  different  observers,  the 
following  were  the  results  : — 

O 


Cruor. 

Serum. 

I^ibrin. 

Water. 

Iron. 

Total. 

1. 

Chlorotic  female 

83.10 

83.45 

'6.35 

832.45 

4.35 

4000 

2. 

Healthy 

do. 

134.00 

88.20 

25.70 

743.90 

8i20 

1000 

“As  a general  rule,  it  may  be  inferred  from  the  experi- 
ments of  MM.  Andral  and  Gavarret,  the  proportion  of  red 
particles  is  diminished,  whilst  that  of  the  fibrin  remains 
the  same;  so  that  the  clot,  although  small,  may  be  firm, 
and  it  not  unfrequently  exhibits  the  buffy  coat.  In  ex- 
treme cases  of  the  disease,  the  red  particles  have  been 
found  as  low  as  27. 

“ In  two  cases  of  chlorosis  observed  by  M.  Andral,  the 
condition  of  the  globules  seemed  to  be  modified.  They 
were  much  smaller  than  usual,  and  some  of  them  ap- 
peared broken,  as  it  were,  and  scattered  in  fragments  in 
the  field  of  the  microscope.  In  one  of  the  cases  that 
recovered,  he  had  an  opportunity  of  noticing  the  condi- 
tion of  the  blood  in  health,  which  presented  perfect  glo- 
bules, very  different  from  those  he  had  observed  some 
.months  previously.  In  uncomplicated  chlorosis,  the 
proportion  of  globules  has  been  found  as  low  as  33  ; but, 
generally,  it  is  about  50.”  (See  Dunglisori' s Practice  of 
Medicine,  Vol.  II.) 

It  appears  that  in  all  these  cachectic  conditions,  there 
is  a superabundance  of  water  in  the  blood,  on  which,  it 
seems,  depends  the  peculiar  sounds  of  the  larger  blood- 
vessels; the  globules  are  also  as  uniformly  diminished, 
as  we  have  already  seen,  their  normal  proportion  being 
127  in  1000. 

Dr.  Little  observes  : “ The  blood  drawn  from  patients 
laboring  under  serous  polyeemia,  after  being  allowed  to 


CACHEXIA— SEROUS  POLYiEMIA. 


89 


stand  for  a short  time,  shows  a very  large  amount  of 
serum,  with  a corresponding  diminution  in  the  quantity 
of  crassamentum,  a state  of  things  which  we  all  know 
must  exist,  when  regard  is  paid  to  the  elements  which 
are  used  in  its  formation.  To  organic  chemistry  are  we 
indebted  for  a knowledge  of  the  influence  possessed  by 
physical  laws  over  vital  phenomena.  No  one,  at  all  ac- 
quainted with  the  late  discoveries  in  chemistry,  will  for 
a moment  deny  the  necessity  of  the  inorganic  elements 
of  food,  and  to  a partial  absence  of  these,  is  in  a great 
measure  to  he  attributed  the  existence  of  serous  polyEemia 
among  children  in  some  parts  of  the  southern  country. 
In  the  northern  part  of  Middle  Florida  (in  which  w'e 
reside),  the  soil  is  deficient,  to  a great  extent,  in  calcareous 
matter,  and  here  lies  the  foundation  of  the  evil.  The 
principal  breadstuff  of  the  inhabitants  is  Indian  corn 
(which,  under  any  circumstances,  contains  less  lime  than 
wheat),  and  as  vegetable  matter  is  influenced  in  its  con- 
stituents by  the  character  of  the  soil  on  which  it  is  grown, 
it  is  obvious  that  maize  cannot  be  well  adapted  to  the 
nutrition  of  the  system,  wanting  as  it  is  in  calcareous  mat- 
ter. The  same  may  be  said  of  all  other  vegetable  matter 
growing  in  the  country.  Inferior  animals,  feeding  on 
such  material,  in  a very  short  time  feel  the  effects  of  a diet 
destitute  of  inorganic  elements ; they  consequently  seldom 
attain  their  natural  growth,  and  are  wanting  in  that  sound- 
ness which  characterizes  those  of  their  species  which  luxu- 
riate in  the  pastures  of  a region  rich  in  calcareous  matter, 
matter  essential  to  the  nourishment  of  the  system.  The 
diet  of  persons  inhabiting  a section  of  country  partially 
destitute  of  some  of  the  inorganic  constituents  of  the 
human  body  must,  after  a time,  produce  a derangement 
in  the  animal  economy,  the  derangement  being  sooner 
manifest  in  the  young  than  in  the  adult  subject,  and  to 
a much  greater  extent.  This  is  manifest  in  our  own  im- 
7 


90 


CACHEXIA— SEROUS  POLYiEMIA. 


mediate  neighborhood ; very  few  of  the  natives  of  the 
country  are  over  twenty  years  of  age,  their  parents 
having  emigrated  principally  from  the  Carolinas.  Many 
of  the  former  suffer  greatly  from  the  use  of  food  destitute 
of  inorganic  elements,  indicated  by  their  pale  and  bloated 
faces,  while  the  latter,  having  emigrated  after  a full  de- 
velopment of  the  system,  muscular  and  osseous,  and, 
consequently,  not  demanding,  so  imperatively  as  their 
offspring,  a supply  of  mineral  matter  for  a healthy  action 
of  their  system,  suffer  comparatively  very  little.  Ex- 
periments, instituted  by  Chossat,  demonstrate  the  neces- 
sity of  graminiverous  animals  being  supplied  with  lime. 
Pigeons  which  he  supplied  with  wheat,  an  article  con- 
taining but  about  2.80  per  cent,  of  lime,  became,  after  a 
time,  emaciated,  and  finally  died,  but  when  lime  was 
added  to  their  food,  they  increased  in  plumpness.  The 
bones  of  those  that  died  exhibited  a brittleness  not  at  all 
consistent  with  a healthy  state  of  the  osseous  system,  a 
state  of  things  frequently  met  with,  in  the  human  subject, 
during  that  period  when  the  process  of  ossification  is 
going  on  most  rapidly.  Dr.  Le  Conte,  in  an  article 
recently  published  on  geophagy,  mentions,  in  confirma- 
tion of  the  necessity  of  inorganic  elements  in  the  food 
of  all  animals,  that  the  cattle,  in  one  of  the  counties  of 
Georgia,  subsist  on  a species  of  grass  destitute  of  phos- 
phatic  or  calcareous  matter ; and,  that  as  a substitute  for 
these  principles  in  their  food,  are  in  the  habit  of  chewing 
bones,  which  they  do  with  the  head  elevated,  to  prevent 
the  saliva  from  flowing  from  the  mouth,  until  the  bulk 
of  bony  matter  is  reduced  to  a very  small  size,  when  it 
is  rejected,  as  being  of  no  further  service.  These  cattle 
are  lean  and  of  diminutive  stature.  Removal  to  a section 
of  country  with  a different  geological  formation,  does 
away  with  the  habit,  a habit  the  result  of  instinct.  Upon 
the  same  principle  may  be  explained  the  tendency  in 


CACHEXIA— SEROUS  POLYiEMIA. 


91 


some  children  and  pregnant  women  to  dirt-eating,  nature 
urging  them  thus  to  supply  the  deficiency  of,  or  increased 
demand  for,  calcareous  and  saline  ingredients  in  their 
ordinary  food,  a habit  which  experience  has  proved  may 
be  indulged  in,  to  a certain  extent,  without  invariably 
causing  disease,  especially  if  the  subject  of  it  he  not  con- 
fined to  a limited  number  of  articles  of  diet.  We  are 
more  and  more  convinced,  from  daily  observation,  of  the 
truth  of  the  experiments  of  Magendie  and  others,  in 
regard  to  the  necessity  of  a variety  in  diet.  In  the 
families  of  those  who  are  in  the  habit  of  varying  the  diet 
from  time  to  time,  cases  of  serous  polygemia  are  rare, 
while  in  others,  where  the  same  articles  of  diet  are  used 
for  months  in  succession,  the  disease  is  common.”  (See 
Amer.  Journ.  Med.  Sci:,  April,  1846.) 

Since  writing  the  above,  I have  to-day  (May  25th) 
seen  the  following  very  interesting  case,  about  seventeen 
or  eighteen  miles  south  of  Hillsboro’,  Scott  county,  Mis- 
sissippi. The  historical  part  was  given  me  by  her 
mother. 

Miss  Miranda  Goodson,  aged  15,  pale,  or  leucophleg- 
matic  appearance;  has  always  been  so;  her  system  is 
imperfectly  developed,  or,  in  other  words,  she  is  badly 
grown.  Was  taken  about  the  26th  of  January,  1849, 
on  Friday,  with  pains  in  her  hands  and  fingers,  feet  and 
legs.  On  the  ensuing  Monday  morning,  the  pains 
became  very  severe;  the  extremities  were  cold  and 
swollen,  and  dark  purple  spots  appeared  on  the  backs  of 
the  hands,  on  the  feet  and  back  part  of  the  legs,  which 
turned  black  in  a fewT  days.  Three  weeks  after  this,  the 
dark  spots  increased  in  size,  and  the  extremities  began 
to  rot  off.  In  five  or  six  weeks,  the  right  hand  first  came 
off  above  the  wrist,  and  soon  after  both  feet  came  off 
above  the  ankles,  the  right  one  the  highest  up.  The 
thumb  of  the  left  hand,  and  the  index  finger  at  the  middle 


92 


CACHEXIA— SEROUS  P-OLYZEMIA. 


joint,  also  sloughed  off.  A dark  spot  appeared  on  each 
cheek,  and  one  on  the  end  of  the  nose,  which  ulcerated, 
but  all  of  which  are  now  cicatrized.  Ulcers  also  came 
on  the  back  part  of  both  arms,  extending  from  the  elbow 
to  near  the  shoulder,  which  is  at  present  healing.  There 
are  ulcers  on  her  knees.  The  ends  of  the  stumps  are 
healing,  being  now  nearly  or  quite  healed  over.  The 
ends  of  the  bones  were  sawed  a little,  by  Dr.  Heslep,  but, 
being  as  thin  as  egg-shells,  easily  broke  away  or  crum- 
bled off.  Her  spleen  has  been  enlarged  three  years,  and 
she  complains  of  pain  in  it  occasionally,  which  was  the 
case  before  she  was  taken  sick.  She  has  had  fever  seve- 
ral times,  but  never  ague  and  fever.  She  has  spinal 
irritation,  tenderness  on  pressure  from  the  lower  part  of 
the  neck  to  the  lower  portion  of  the  loins,  being  less 
manifest  in  the  lower  portion  of  the  dorsal  region.  She 
is  now  restless  at  night.  When  she  draws  a long 
breath  every  bone  pains  her,  and  feels  as  though  it  would 
burst.  The  tendons  on  the  back  of  the  knees  are  con- 
tracted and  firm,  and  the  legs  bent;  she  can  flex  and  ex- 
' tend  her  legs  a little.  There  are  some  watery  blisters  on 
the  back  of  the  legs  just  above  the  ulcers,  which  latter 
extend  some  distance  up  the  back  part  of  the  legs.  She 
has  pains  in  her  loins,  which  are  much  more  intense  once 
every  month.  She  has  never  had  her  catamenia.  Her 
mind  is  much  impaired,  recollecting  nothing  that  trans- 
pired during  her  sickness,  till  about  two  weeks  back; 
though  she  still  recollects  things  previous  to  her  sickness. 
She  appears  to  be  improving  a little. 

On  the  Saturday  succeeding  the  Monday  on  which 
she  was  so  violently  taken,  she  had  convulsive  fits,  which 
lasted  till  Sunday,  about  noon.  She  was  at  this  time 
cupped  and  blistered  on  the  back  of  the  neck.  She  was 
bled  on  the  Monday  she  was  so  violently  taken  ; but  little, 
however,  could  be  procured  or  drawn,  and  what  was  oh- 


CACHEXIA— SEROUS  POLYiEMIA. 


93 


tained  was  very  watery,  and  would  scarcely  stain  linen. 
She  has  taken  opium,  but  it  procured  but  little  relief  of 
pain  and  restlessness.  One  attendant  physician  gave 
her  a few  blue  mass  pills.  Her  eyes  were  naturally  blue; 
during  her  sickness  they  turned  black,  but  are  now  be- 
coming blue  again.  In  the  severer  periods  of  her  sick- 
ness, the  pulse  was  many  times  scarcely  perceptible. 

Remarks. — The  parents  of  the  above  girl  are  poor,  and 
living  in  a poor,  sandy,  piny  region  of  country.  The 
condition  of  her  system  is  manifestly  referable  to  a want 
of  inorganic  elements — to  a want  of  proper  and  sufficient 
nourishment.  In  this  region  of  Mississippi,  cattle,  and 
even  hogs,  instinctively  chew  bones,  in  order  to  obtain 
calcareous  and  phosphatic  matter,  which  their  food  here 
does  not  supply  in  sufficient  amount.  It  is  said,  that 
when  they  are  removed  to  a region  of  country  where 
there  is  limestone  water,  and  where  the  land  is  much 
more  rich  and  productive,  they  quit  the  custom  of  chew- 
ing bones.  It  can  be  observed  in  the  complexion  or 
pallid  appearance  of  many  children,  and  some  grown 
persons,  in  this  region,  that  the  system  is  wanting  in  in- 
organic compounds;  as,  lime,  iron,  etc. 

In  conclusion,  I will  mention  an  interesting  circum- 
stance which  occurred  in  a cow,  belonging  to  Wm. 
Chambers,  Esq.,  of  Hillsboro’,  Mississippi.  The  fact 
was  communicated  to  me  by  Mrs.  Chambers.  In  the 
spring  of  1843,  the  cow’s  tail  rotted  off  some  distance 
from  the  root.  The  cow  appeared  to  be  in  bad  health, 
and  her  hair  very  rough.  She  has  since  been  observed 
to  chew  bones  for  two  or  three  hours  in  the  mornincr.  I 

O 

have  seen  her  at  this  myself. 

When  the  watery  portion  of  the  blood  so  largely  pre- 
dominates, connected  as  it  is  with  debility,  relaxation,  or 
flabbiness  or  softness  of  the  flesh,  and  especially  if  some 
visceral  disease  exist,  need  we  be  surprised  that  dropsical 


94 


TUBERCULOUS  CACHEXIA— CONSUMPTION,  ETC. 


effusions  take  place  into  the  different  serous  cavities,  or 
into  the  cellular  substance,  producing  anasarca,  hydro- 
thorax, ascites,  hydrocele,  hydrops  pericardii,  etc.  ? 

The  chronic  bronchitis,  which  not  unfrequently  comes 
on  during;-  this  cachectic  condition,  will  receive  attention 
when  we  come  to  notice  its  treatment,  as  will  also 
haemoptysis,  etc.  etc. 

' / 


CHAPTER  IV. 

TUBERCULOUS  CACHEXIA— CONSUMPTION,  &c. 

The  limits  of  this  work  will  not  allow  of  a full  con- 
sideration of  this  very  important  subject.  I hope,  how- 
ever, that  the  brief  consideration  which  we  may  give 
to  it,  will  not  be  without  profit  to  those  who  may  feel  in- 
terested enough  to  carefully  peruse  it.  Considering  the 
grave  character  of  tuberculosis,  and  the  larg-e  amount  of 
the  human  family  that  suffer  from  it,  it  is  certainly  one 
of  the  most  important  subjects  belonging  to  the  whole 
domain  of  medicine ; and  though  more  common  on  some 
portions  of  the  globe  than  others,  it  may,  in  the  language 
of  Professor  Bartlett,  with  respect  to  consumption,  be 
regarded  as  the  “ endemic  of  the  world manifesting 
itself  in  the  torrid,  temperate,  and  frigid  zones;  and  in 
the  different  races,  ages,  sexes ; and  also  amongst  some 
of  the  lower  animals. 

There  are  modifications  in  tuberculosis,  or  tuberculous 
cachexia,  and  different  names  have  been  given  to  indicate, 
or  as  referable  to  these  modifications,  and  . to  the  deposit 
of  tubercular  matter  in  certain  parts.  The  most  import- 
ant of  these  is  its  deposit  in  the  lungs,  commonly  called 


TUBERCULOUS  CACHEXIA— CONSUMPTION,  ETC. 


95 


Phthisis  Pulmonalis , or  Consumption.  When  the  depo- 
sit takes  place  into  the  lymphatic  glands  about  the  neck, 
it  is  called  scrofula;  when  into  the  glands  of  the  mesen- 
tery, tabes  mesenterica  ; when  into  the  meninges  or  mem- 
branes, and  surface  of  the  brain,  tubercular  meningitis , or 
hydrocephalus  internus , etc.  etc.  Indeed,  this  tubercular 
deposit  may  take  place  in  any  organ  or  tissue  of  the 
body,  producing  a variety  of  symptoms,  according  to  the 
structure,  nature,  and  functions  of  the  organ  or  organs 
in  which  it  is  deposited,  and  the  degree  of  irritation  and 
inflammation  which  it  may  produce.  Even  the  bones 
and  ligaments  about  the  joints  become  diseased  in  some 
who  are  scrofulous.  This  takes  place  in  scrofulous  chil- 
dren, and  is  known  by  the  name  of  “ white  swelling .” 
That  affection  of  the  spine,  making  it  crooked,  with 
crookedness  of  the  long  bones,  and  swelling  of  their  ex- 
tremities, known  by  the  common  name  of  “ rickets f 
usually  occurring  in  weakly  children,  that  are  born  of 
scrofulous  or  rickety  parents,  and  which  live  in  damp  or 
confined  situations,  without  sufficient  and  proper  nour- 
ishment and  exercise,  is  another  modified  form  of  scrofu- 
lous disease.  But  suffice  it  to  say,  the  peculiar  abnormal 
condition  of  the  blood  in  the  tuberculous  cachexia , may 
give  rise  to  the  deposit  of  tubercular  matter  in  any  tissue 
or  organ,  or  in  many  parts  at  the  same  time,  producing 
corresponding  phenomena,  if  of  sufficient  amount  to 
cause  irritation,  inflammation,  and  suppuration.  Like 
inflammation  under  certain  circumstances,  the  determi- 
nation or  deposition  of  the  tuberculous  matter  in  one 
part,  seems  to  act  as  a revulsive,  or  to  lessen  its  deposition 
in  other  parts ; and  from  failing  to  recognize  this  simple 
law,  is  probably  the  reason  why  many  authors  have 
denied  the  identity  of  the  tuberculous  and  scrofulous 
diatheses.  In  some  cases,  the  tuberculous  matter  which 
is  in  the  blood  may  not  be  deposited  in  any  part,  but 


96 


TUBERCULOUS  CACHEXIA— CONSUMPTION,  ETC. 


escape  through  some  of  the  mucous  surfaces  or  kidneys; 
in  this  latter  case  producing  albuminuria  ; in  which,  how- 
ever, the  substance  of  the  kidneys  themselves  too  often 
suffer  from  the  deposit  into  them. 

Charles  Frick,  M.  D.,  of  Baltimore,  has  recently  ex- 
amined the  blood  of  eight  persons  suffering  with  con- 
sumption. I make  the  following  extract : — 

uPulmonary  Tubercles. — We  have  examined  the  blood 
of  eight  persons  suffering  with  this  disease.  In  four,  the 
tubercles  were  as  yet  crude,  while  in  the  others  they  had 
softened,  and  cavities  had  formed.  In  No.  5,  there  was 
a very  large  cavity  and  extensive  tuberculization  in  both 
lungs;  and  in  No.  7,  a man  aged  70,  there  was  a cavity 
in  each  lung.  In  comparing  these  two  classes  of  cases, 
we  have  found  a marked  difference.  The  average  for 
the  fibrin  in  the  first  four,  in  which  cases  the  tubercles 
were  unsoftened,  is  2.776,  about  normal;  while  in  the 
others  it  is  4.114.  This  result  is  similar  to  that  obtained 
by  Andral.  The  albumen  in  every  case  is  above  the 
natural  standard,  although  not  so  apparently.  We  have 
carried  out  the  proportion  that  it  bears  to  the  whole 
amount  of  solids  in  a separate  column,  and  the  fact  that 
such  is  the  case  will  be  seen  by  reference  to  it.  This  is 
also  true  of  each  one  of  Andral’s  cases,  although  he  seems 
not  to  have  noticed  it;  for  we  find  the  average  in  his  to 
be  94.3,  while  in  ours  it  is  only  87.847.  The  difference 
between  the  two  stages  is  also  apparent,  the  average  for 
the  first  set  being  90.83,  and  for  the  other  84.35.  We 
make  the  following  suggestions  in  regard  to  the  increase 
of  this  material.  Albumen  is  deposited  in  all  the  tissues 
as  a result  of  secondary  assimilation;  and  we  suppose 
that,  in  a tubercular  diathesis,  the  vitality  is  not  sufficient 
to  carry  it  one  grade  further,  and  change  it  into  globules, 
but  allows  it  to  remain  as  albumen,  a nucleus  for  the  de- 
position of  tubercular  matter,  or  perhaps  to  be  changed 


TUBERCULOUS  CACHEXIA— CONSUMPTION,  ETC.  97 

itself  into  it.  This  albumen  is  deposited  alike  in  every 
individual,  but  it  is  only  in  a tubercular  diathesis,  or 
where  the  vitality  is  lowered,  that  it  is  converted  into 
tubercle.  Andral  says,  that  tubercular  matter  is  never 
deposited  so  long  as  the  globules  remain  at  their  proper 
standard,  and  that  when  this  deposition  first  takes  place, 
they  are  always  found  lowered;  and  we  may  add,  that 
the  albumen  is  always  found  increased.  This  change  is 
probably  not  an  evidence  that  they  are  about  to  be  de- 
posited, as  he  also  thinks  ; but,  that  the  albumen  remains 
unconverted  into  globules,  accounting  for  the  increase  of 
the  one,  and  the  diminution  of  the  other. 

“ The  iron  and  chlorides  follow  the  laws  noticed  pre- 
viously; while  a marked  difference  is  perceptible  in  both 
the  lime  and  phosphates  in  the  two  contrasted  stages. 
In  the  first  set,  the  lime  in  every  case  is  above  the  stand- 
ard, while  the  phosphates  are  below ; the  average  for  the 
first  being  0.277,  and  for  the  other  0.272;  whilst,  in  the 
other  set,  the  average  is  0.083  for  the  lime,  and  1.265  for 
the  phosphates.  This  difference  in  the  phosphates  can- 
not be  accounted  for  by  the  season  of  the  year,  for,  on 
making  the  average  from  the  table  previously  given,  we 
obtain  0.952  for  the  first  set,  and  1.202  for  the  second  ; 
above  what  is  here  found  in  the  one  case,  and  below  it 
in  the  other.  It  may  be,  that  these  salts  compensate,  in 
a measure,  for  one  another;  or,  perhaps  the  excess  of  the 
phosphates,  occurring  as  they  do,  in  the  cases  which 
have  been  some  time  in  the  hospital,  may  arise  from  the 
fact,  that  these  persons  are  constantly  taking  into  their 
systems  ammonia,  of  which  there  is  always  more  or  less* 
in  every  room  where  patients  are  collected  together.” 


98 


TUBERCULOUS  CACHEXIA— CONSUMPTION,  ETC. 


| No.  of  case.  | 

Solids  in 
1000  grains. 

Water  in 
1000  grains. 

Fibrin. 

Globules. 

Solids  of 
the  serum. 

Ditto,  propor- 
tionate to 
whole  solids. 

Iron. 

Lime. 

Chlorides  of 
soda  and 
potash. 

Phosphates 
of  soda  and 
potash. 

Date  of 
sickness. 

1 

212.631 

789.369 

3.395 

125.645 

86.546 

87.23 

.564 

.272 

2.530 

.336 

August  20. 

2 

199.666 

800-334 

2.688 

111.453 

85.525 

90.30 

.487 

.257 

5.632 

.197 

March  22. 

3 

200.602 

799.398 

2.862 

117.480 

80.260 

84.31 

.510 

.296 

4.822 

.203 

June  1. 

4 

207.007 

802.993 

2.159 

104.600 

100.248 

101.46 

.416 

.283 

2.910 

.351 

October  1. 

5 

169.000 

831.000 

5.250 

94.S33 

68.917 

85.83 

.384 

.082 

3.992 

1.616 

March  3. 

6 

198.053 

801.947 

4.502 

117.405 

76.046 

80.63 

.470 

.182 

5.500 

1.462 

February  1. 

7 

155.000 

S45.000 

2.352 

91.456 

61.192 

82.94 

.376 

.027 

3.560 

1.278 

Nov.  6. 

8 

167.436 

832.564 

4.353 

93.061 

70.022 

88.00 

.391 

.040 

3.924 

.705 

Nov.  23. 

Average. 

3.145 

100.604 

76.844 

87.84 

.449 

.179 

3.722 

.775 

Causes. — The  causes  of  the  tuberculous  cachexia  may- 
consist  (1)  of  an  original  conformation,  tuberculous  con- 
stitution, diathesis,  or  predisposition  ; or,  (2),  they  may 
be  secondary  or  accidental. 

Of  the  former,  or  liereditanj  conformation,  Professor 
Dunglison.  remarks,  that  “ This  is  one  of  the  most  im- 
portant of  the  causes  of  tuberculosis,  and  especially  of 
tubercular  phthisis.  A patient,  affected  with  tuberculous 
cachexia,  entails  on  his  offspring,  not  tubercles,  but  a 
predisposition  to  them,  -which  may  be  warded  off,  by 
avoiding  the  exciting  causes,  but  may  be  developed  by 
causes  which  would  be  entirely  inoperative  in  one  not 
so  predisposed.  It  is  important,  therefore,  in  the  history 
of  any  case,  to  discover  whether  the  parents,  or  any 
member  of  the  family,  have  died  of  the  same  disease.  It 
would  not  appear  to  be  tuberculous  cachexia  alone,  in  the 
parent,  which  lays  the  foundation  for  this  fatal  malady  in 
the  offspring.  There  are  several  diseases  which  have 
been  supposed  to  produce  the  result,  and  the  most  fre- 
quent and  important  of  these  are  disordered  states  of  the 
digestive  organs,  and  their  consequences;  indeed,  any 
state  of  deteriorated  health  in  the  parent,  from  any  cause, 
may  give  rise  to  this  cachexia  in  the  progeny.”  Pro- 
fessor Dunglison  further  remarks:  “It  has  been  stated, 
that  the  tuberculous  constitution  is  often  communicated 


CONSUMPTION. 


99 


by  the  parent  to  the  progeny.  In  the  way  of  hygiene, 
it  is,  therefore,  important,  that  precautions  should  be 
taken  by  parents  themselves,  and  every  step  be  avoided 
that  can  deteriorate  their  own  general  health.  If  more 
consideration  were  bestowed  on  matrimonial  alliances, 
and  a more  healthy  and  natural  mode  of  living  were 
adopted  by  persons  in  that  station  of  life  which  gives 
them  the  power  of  regulating  their  mode  of  living  ac- 
cording to  their  own  choice,  the  predisposition  which  is 
so  often  entailed  upon  their  offspring  might  be  checked, 
and  even  extinguished,  in  their  family,  in-  the  course  of 
a few  generations.  ‘ The  children  of  dyspeptic  persons,’ 
observes  Sir  James  Clark,  ‘generally  become  the  subjects 
of  dyspepsia  in  a greater  degree,  and  at  an  earlier  period, 
than  in  their  parents ; and  if  they  marry  into  families  of 
a delicate  constitution,  their  offspring  become  highly  tu- 
berculous, and  die  of  phthisis  in  early  youth,  and  even 
in  childhood.’  These  remarks  are  unquestionably  just ; 
but  how  impossible  is  it  to  regulate  the  feelings  of  indi- 
viduals, so  that  any  prudential  restraints  shall  be  re- 
garded. Every  practitioner  who  has  been  consulted 
respecting  the  propriety  of  marriage,  where  one  or  both 
of  the  parties  have  labored  under  a disease,  or  a predis- 
position unquestionably  hereditary  in  its  nature,  and  who 
has  given  advice  befitting  the  occasion,  must,  at  times, 
have  had  the  mortification  to  find  his  advice  wholly  dis- 
regarded, and  that  he  has,  at  the  same  time,  for  ever  lost 
the  good  opinion  of  both  parties.  On  the  part  of  the 
mother,  care  is,  doubtless,  demanded,  for  the  plenary 
health  of  the  offspring,  during  the  period  of  gestation. 
But  the  prevention  of  hereditary  transmission  regards 
rather  the  condition  of  both  parents  at  the  time  of  a fe- 
cundating union ; for  the  predisposition  is  as  often  given 
by  the  male  as  by  the  female  parent.  If  the  tuberculous 


100 


TUBERCULOUS  AFFECTIONS. 


diathesis  be  induced  during  intra-uterine  existence,  it 
belongs  to  the  class  of  acquired  predispositions.” 

It  is  a subject  of  great  importance,  that  those  who  an- 
ticipate a connubial  life,  should  compare  their  own  phy- 
sical conformation  and  temperament  with  that  of  their 
anticipated  companion,  so  that  a congruous  match  will 
be  formed  physically,  as  well  as  mentally,  which  will 
tend  to  confer  a vigorous  constitution  to  their  offspring. 
I consider  this  a duty  to  which  both  males  and  females 
should  pay  sufficient  heed;  not  only  in  justice  to  them- 
selves, but  also  to  others  who  may,  in  any  way,  be  affect- 
ed or  interested  thereby ; as,  for  instance,  their  progeny, 
relatives,  neighbors,  and  their  country.  Parents  should 
teach  their  children  the  importance  of  attention  to  this 
subject,  the  nature  of  their  physical  conformation  and 
temperament,  and  point  out  the  form  and  temperament 
to  which  theirs  is  adapted.  This  should  be  done  before 
uncontrollable  attachments  have  been  formed.  These 
remarks  are  applicable,  not  only  to  avoid  tuberculous 
affections,  but  any  conformation  which  has  a tendency 
to  develop  disease  of  any  kind ; as,  for  instance,  the  short, 
thick  neck  and  large  chest,  which  favor  the  develop- 
ment of  apoplexy.  These  principles  are  taken  advan- 
tage of  by  farmers,  in  “ crossing ” their  stock,  in  order  to 
improve  it. 

(2  ) Among  the  secondary  or  accidental  causes  (if  we 
may  be  allowed  to  term  them  as  such,  though  they  may 
be  primary),  we  may  mention  the  protracted  cachectic 
conditions  which  we  have  heretofore  noticed,  as  the  re- 
sult of  protracted  ague  and  fever , or  as  the  result  of  living 
in  low , damp,  malarious , or  unhealthy  situations,  and  the 
deprivation  of  proper  and  sufficient  nourishment.  Authors 
mention  the  deprivation  of  light  as  a cause  of  tubercu- 
losis, as  is  exemplified  in  the  workers  in  mines,  and  those 
poor  families  which  live  in  cellars;  but  without  denying 


TUBERCULOUS  AFFECTIONS. 


101 


the  influence  of  light,  under  these  circumstances,  no  doubt 
much  more  depends  on  want  of  proper  ventilation,  con- 
finement in  close,  damp,  and  confined  apartments,  where 
the  air  is  impure,  and  unwholesome  or  improper  alimen- 
tation. The  inhalation  of  small  particles  of  foreign  mat- 
ter by  stonemasons,  fork  grinders,  workers  in  factories, 
&c.,  for  a long  time,  may  produce  tuberculosis.  Pro- 
tracted inflammatory  affections  of  the  air-passages,  espe- 
cially if  the  general  health  suffers  much,  tend  to  the 
formation  of  tubercles  in  the  lungs.  Some  diseases,  es- 
pecially where  predisposition  exists,  also  tend  to  the 
production  of  tuberculous  disease;  as,  measles,  syphilis, 
scurvy,  &c.  &c. 

Of  late  years,  some  few  have  entertained  an  erroneous 
opinion,  that  there  is  an  antagonism  between  marsh  fever 
and  consumption ; and  that  malarious  districts  should, 
therefore,  be  favorite  residences  of  the  phthisical,  or  those 
so  predisposed.  Up  to  this  time,  I have  spent  nearly  all 
of  my  life  in  malarious  regions, — and  have  observed,  that 
not  only  many  die  of  consumption  in  these  regions — that 
the  more  virulent  the  malarial  region,  the  greater  the 
fatality  from  consumption,  all  other  things  being  equal — 
but  that  protracted  or  chronic  malarious  diseases,  pro- 
ducing a cachectic  condition,  and,  perhaps,  some  conco- 
mitant visceral  disease,  are  frequent  causes  of  consump- 
tion. To  the  correctness  of  this  statement,  not  a few 
southern  and  western  practitioners  can  testify.  It  ap- 
pears that  Professor  John  P.  Harrison,  of  Cincinnati, 
does  not  believe  that  these  two  diseases  are  antagonistic. 
Professor  Dunglison  says,  “ The  results  obtained  statis- 
tically in  the  West  Indies,  by  no  means  favor  an  opinion 
that  there  is  an  antagonism  between  diseases,  which  are 
the  product  of  marshy  emanations  and  phthisis ; that  they 
prevail  together,  without  seeming  to  exert  any  influence 
upon  each  other.  Dr.  Harden,  of  Georgia,  is  of  opinion 


102 


MICROSCOPIC  APPEARANCE  OF  TUBERCLE. 


that  there  is  one  form  of  consumption,  different  from  the 
others,  known  among  writers  as  catarrhal  phthisis , or 
chronic  bronchitis,  which  properly  belongs  to  our  species 
of  marsh  or  intermittent  fever;  and,  instead  of  bein<r 
antagonistic,  is  isopathic  with  the  fevers  of  malarious 
regions. 

I am,  however,  inclined  to  the  opinion,  that  some  ma- 
larious districts  possess  some  advantages  over  certain 
other  portions  of  the  globe,  for  the  consumptive. 

‘ ' ‘t  ‘ ‘ • ■ fc; 

Tubercle.— Professor  Dunglison  says:  “Tubercle, 
in  the  simplest  and  most  common  form,  is  a small,  yel- 
lowish-white body,  of  a round  shape,  firm  consistence, 
and  sufficiently  hard  to  be  crushed  in  many  cases ; in 
others,  of  the  consistence  of  viscid  pus,  or  cheese.  It 
varies  in  size  from  that  of  a millet-seed,  to  that  of  a pea 
or  nut.  It  is  without  any  trace  of  organization  or  texture  ; 
is  sometimes  isolated  ; at  others  agglutinated  in  masses, 
of  greater  or  less  dimension ; sometimes  infiltrated  into 
the  parenchyma  of  the  lungs,  and  occupying  one  or  more 
lobules — at  others,  a lobe,  or  even  the  whole  lung.  Tu- 
bercles are  very  rarely  single  or  solitary,  and  their  num- 
ber varies  greatly.  They  are  commonly  situated  at  the 
top  of  the  lung,  and  when  they  are  met  with,  in  the  in- 
ferior lobes,  they  are  always  in  a less  advanced  stage  of 
existence  than  those  of  the  superior  lobes.” 

Microscopic  Appearances  of  Tubercle. — According 
to  M.  Lebert,  tubercle  is  composed  of:  1.  “A  great 
quantity  of  molecular  granules,  perfectly  round,  having 
a diameter  varying  from  yg1^  to  of  a line;  2.  A hya- 
line substance,  rather  consistent,  and  uniting  together  the 
preceding;  3.  Globules  proper  to  tubercles.  The  latter 
constitute  the  peculiar  characteristics  of  this  morbid  pro- 
duct, and  are  thus  described  : Their  form  is  rarely  alto- 


MICROSCOPIC  APPEARANCE  OF  TUBERCLE.  103 

gether  round,  although  it  is  probable  that,  on  their  first 
deposition,  they  approach  the  spherical  figure,  and  that 
they  assume  a less  regular  and  often  angular  contour,  as 
we  see  in  so  many  other  analogous  instances,  from  their 
juxta-position.  They  are  of  a clear  yellow  color,  and 
contain  granules,  but  no  distinct  nucleus.  These  tuber- 
culous globules  vary  considerably  in  their  size,  but  with- 
out any  definite  relation  to  the  age  of  the  subject,  or  to 
the  organs  in  which  they  exist.  After  contrasting  the 
globules  in  question  with  those  of  pus,  cancer,  and  en- 
cephaloid,  M.  Lebert  thus  expresses  himself:  ‘Tubercle 
then,  contains,  in  its  crude  state,  an  element  which  is 
peculiar  to  it,  and  which  distinguishes  it  from  all  other 
morbid  'productions?”*  M.  Lebert  says,  these  globules 
“are  not  affected  by  water,  ether,  and  the  feeble  acids; 
but  they  are  dissolved  by  the  strong  acids,  as  well  as  by 
ammonia  and  caustic  potash. 

“The  opinion  of  certain  pathologists,  that  tuberculous 
deposit  and  its  globules  are  only  modifications  of  puru- 
lent matter,  is  contradicted  by  the  result  of  microscopic 
inspection  ; the  differences  between  them  are  strong  and 
decided.  The  corpuscles  of  the  latter  are  considerably 
larger,  of  a regular  spherical  shape,  and  contain  from  one 
to  three  nuclei ; they  are,  moreover,  usually  free  and  iso- 
lated ; whereas  those  of  tuberculous  matter  are,  especi- 
ally in  the  crude  state  of  tubercles,  closely  joined  together. 
The  globules  of  cancerous  matter  are  twice,  or  even  four 
times  as  large,  and  they  contain  a nucleus,  in  which 
again  from  one  to  three  nuclei  are  often  observable. 

“In  sarcocele,  and  also  in  scirrhous  and  encephaloid 
tumor  of  the  mamma  {breast),  we  not  unfrequently  find 
a yellowish,  cheesy-looking  substance,  which  much  re- 
sembles genuine  tuberculous  matter ; but  a careful  ex- 


* Med.  Chir.  Rev.,  Jan.  1846,  p.  243.  Am.  Journ.,  Oct.  1847,  p.  344. 


104 


MICROSCOPIC  APPEARANCE  OF  TUBERCLE. 


amination  with  the  microscope,  clearly  shows  that  it  con- 
sists entirely  of  globules  of  cancer  infiltrated  with  fat. 

“When  tubercles  soften,  their  interglobular  substance 
liquefies,  the  globules  separate  from  each  other,  and  may 
then,  by  absorbing  a certain  portion  of  the  fluids,  become 
larger;  this  change  does  not  constitute  an  increased 
growth,  but,  on  the  contrary,  the  commencement  of  the 
process  of  decomposition. 

“The  pus,  which  is  found  blended  with  the  softened 
tubercles,  is  supplied  by  the  surrounding  tissues,  and  is 
by  no  means  the  result  of  any  transformation  of  the 
matter  itself;  but  the  pus,  it  must  be  confessed,  quickly 
alters  it,  and  renders  its  elements  much  less  easily  recog- 
nizable. 

“The globules  of  softened  tubercles  become  ultimately 

o j 

dissolved  in  a granular  fluid,  and  thus  the  ramollissement 
( softening ) of  their  substance  passes  fairly  to  the  state  of 
diffluence. 

“ The  cretaceous  condition  of  tuberculous  matter  pre- 
sents, under  the  microscope,  the  appearance  of  amorphous 
mineral  granules,  blended  often  with  crystals  of  choles- 
terine,  and  coloring  matter.  A part  of  the  tuberculous 
globules  is  then  removed  by  absorption,  while  the  other 
portion  remains  for  a long  time  in  an  unchanged  condi- 
tion. 

“ Occasionally  we  find,  in  tuberculous  deposit,  corpus- 
cles of  fat,  melanosis,  greenish-colored  globules,  and  crys- 
tals which  have  the  form  of  those  of  the  ammoniaco-mag- 
nesian  phosphate.  Besides  these  admixtures,  we  may  find 
blended  along  with  them  the  elements  of  inflammatory 
and  suppurative  action,  and  various  sorts  of  epithelial 
exudations ; all  of  which  tend  to  modify  the  essential 
miscroscopic  features  of  the  tubercles.”* 

* Amer.  Journ.  Med.  Sci.,  Oct.  1848,  p.  4G1.  Quoted  by  Dr.  Ilarden,  of 
Ga.,  in  Amer.  Journ.  Med.  Sci.,  Oct.  1847,  pp.  343-4. 


COMPOSITION  OF  TUBERCLE. 


105 


Composition  of  Tubercle.— -From  chemical  analyses 
which  have  been  made,  it  appears  that  tuberculous  mat- 
ter varies  somewhat  in  its  composition,  but  that  by  far 
the  largest  proportion  of  it  is  composed  of  albuminous 
matter.  M.  Thenard  found  the  following  : — 

• 1st.  Animal  matter  (albuminious  chiefly)  98.15 

(•  Muriate  of  soda  \ 

2d.  -j  Phosphate  of  lime  l 1.85 

t Carbonate  of  lime) 

3d.  Iron  a trace. 

. . - * • ' " • -v. 

The  following  is  the  mean  of  two  analyses  by  Dr. 
Wright: — 

1st.  Fatty  matter  with  oil  globules  11.69 
2d.  Gelatine  9.1 

r Phosphates  •)  T . 

3d.  j Sulphates  f SodiT  ] 6-85 

( Muriates  1 

4th.  Carbonate  of  lime  a trace 

5th.  Oxide  of  iron  a trace 

6th.  Albuminous  matter  with  fibrin  70.6 

“ The  chief  organic  constituents  of  tubercle,  according 
to  the  analyses  of  M.  Hasse,  are  : 1st,  fibrin  ; 2d,  casein ; 
3d,  fat ; with  4th,*  a small  proportion  of  albumen.  The 
inorganic  compounds  are  : chloride  of  sodium,  phosphate 
of  soda,  phosphate  and  carbonate  of  lime,  oxide  of  iron, 
&c.”* 

After  reviewing  the  analyses,  Dr.  Bennet  comes  to  the 
following  conclusions 

“ 1.  That  tubercle  consists  of  an  animal  matter  mixed 
with  certain  earthy  salts. 

“2.  That  the  relative  proportion  of  these  varies  in 
different  specimens  of  tubercle.  That  animal  matter  is 

* Quoted  by  John  M.  B.  Harden,  M.  D.,  of  Liberty  county,  Georgia.  For  a 
more  detailed  notice  of  this  subject,  I would  refer  the  reader  to  an  interest- 
ing paper,  with  numerous  quotations,  by  Dr.  Harden,  on  Isopathia,  or  the 
parallelism  of  diseases . See  Amer.  Journ.  Med.  Sci.,  Oct.  1847. 

8 


106 


SCROFULOUS  MATTER— COMPOSITION  OF. 


most  abundant  in  recent,  and  earthy  salts  in  chronic 
tubercle. 

“ 3.  That  the  animal  matter  certainly  contains  a large 
amount  of  albumen.  Some  chemists  have  detected 
casein,  the  existence  of  which  is  probable ; others  gela- 
tin, the  presence  of  which  is  more  doubtful;”  and  “ that 
very  little  difference  in  ultimate  composition  has  yet  been 
detected  between  recent  tubercles,  and  other  so-called 
compounds  of  protein.” 

Dr.  Carswell  believes  the  chemical  composition  of  tu- 
bercle to  vary  at  different  periods  in  different  animals, 
and  probably  in  different  organs.  In  man,  being  com- 
posed chiefly  of  albumen  with  various  proportions  of 
gelatin  and  fibrin. 

Scrofulous  Matter. — J.  M.  B.  Harden,  M.  D.,says: 
“ According  to  the  analyses  of  scrofulous  matter  by  Prout, 
Gendrin,  and  Bredon,  as  given  us  by  Mr.  Phillips,  in  his 
late  work  on  Scrofula , it  is  made  upj  for  the  most  part, 
of  albumen,  like  tubercle.  Dr.  Prout  regarded  scrofu- 
lous matter  as  albumen  imperfectly  developed;  Gendrin 
as  a mass  of  albumen  with  excess  of  salts;  Bredon  con- 
siders it  to  be  an  albuminate  of  potash  and  soda.” 

When  tubercles  are  small  ( miliary  tubercles),  if  the 
peculiar  condition  of  the  system  which  gave  rise  to 
their  deposition  be  changed  to  a healthy  one,  their  fur- 
ther development  may  be  arrested,  and  the  individual’s 
life  may  be  very  little,  if  at  all,  shortened  thereby : but  if 
his  or  her  health  .should  become  seriously  affected,  for 
some  time,  late  in  life,  there  is  a great  liability  to  the 
renewed  development  of  tubercles,  especially  in  the  lungs, 
and  if  great  care  is  not  taken  in  time,  and  the  proper 
course  pursued,  death  will  be  very  likely  to  ensue.  These 
remarks  apply,  but  generally  with  less  force,  to  earlier 
periods  of  life. 


SCROFULOUS  MATTER— COMPOSITION  OF. 


107 


When  tubercles  have  been  deposited  or  formed  in  suf- 
ficient amount  to  produce  irritation  apd  inflammation, 
succeeded  by  ulceration , which  they  do  in  a longer  or 
shorter  period,  the  pus  bathes  the  tuberculous  matter  and 
softens  it,  and  an  abscess  is  formed  which  makes  its  way 
outwardly;  if  in  the  lungs,  making  its  way  into  the 
bronchia,  and  the  matter  is  thrown  up  by  coughing,  by 
expectoration.  A cavity  is  thus  formed/*  in  the  lungs, 
which,  under  favorable  circumstances,  may  cicatrize ; 
but  usually  there  are  other  tubercles  forming  in  the 
neighborhood  of  it,  which  are  apt  to  be  more  copious  the 
greater  the  surrounding  inflammation,  and  which  usually, 
sooner  or  later,  become  sufficiently  developed  to  take  a 
similar  course  to  the  previous  ones,  and  which  may  com- 
municate with,  and  enlarge  the  former  cavity  by  the  ad- 
dition of  the  new  one ; or  a new  cavity  or  cavities  may 
be  formed,  successively  or  cotemporaneously,  till  a con- 
siderable portion  of  one  or  both  lungs  may  be  destroyed. 
A cavity  may  cicatrize,  and,  under  proper  treatment  and 
favorable  circumstances,  the. further  deposition  of  tuber- 
cles may  be  arrested,  and  the  patient’s  health  restored ; 
but  not  unfrequently  a truce,  of  some  months  or  years, 
inspires  the  individual  with  the  feeling  of  immunity; 
when,  especially  under  favorable  circumstances  for  their 
development,  a renewed  deposition  of  tubercles  takes 
place,  which  pursue  a similar  course  to  the  other  crop 
or  crops,  till  the  lung  or  lungs  become  so  much  de- 
stroyed, hsematosis  is  imperfect,  the  general  health  be- 
comes more  impaired,  wasting  away  of  the  body  takes 
place  as  nutrition  becomes  more  and  more  impaired,  till 
death  is  triumphant  over  vitality,  and  the  body  is  sub- 
ject to  the  ordinary  laws  of  decomposition.  Sometimes 
the  abscess  may  destroy  a blood-vessel  sufficiently  large 
to  produce  hcemoptysis,  and  if  the  hemorrhage  is  copious, 
death  might  ensue  therefrom  or  thereby,  though  this  is 


108 


CONSUMPTION. 


rarely  the  case.  In  some  cases,  the  abscess  or  cavity 
has  extended,  or  made  its  way,  into  the  cavity  of  the 
chest,  producing  pneumothorax  and  pleurisy ; or  the  pleu- 
ra pulmonalis  and  pleura  costalis  may  adhere  and  grow 
together  by  means  of  adhesive  inflammation,  and  the  ab- 
scess may  make  its  way  out  through  the  walls  of  the 
chest.  This,  however,  is  rarely  the  case. 

Hoarseness  is  usually  an  early  symptom  of  consump- 
tion, and  when  there  is  much  ulceration  in  the  larynx, 
the  hoarseness  is  much  more  manifest,  the  voice  often 
becoming  very  feeble,  or  even  entirely  extinct.  A large 
amount  of  the  expectorated  matter  comes  from  the  larynx, 
trachea,  and  bronchia  ; the  softened  tubercles  and  pulmo- 
nary excavations  not  being  the  only  source  of  it. 

Generally,  tuberculous  matter  is  simultaneously  de- 
posited in  other  parts  of  the  system,  especially  along  the 
alimentary  canal,  in  the  latter  stages  of  consumption;  at 
which  time  there  is,  most  commonly,  inflammation,  which 
passes  to  ulceration  of  the  mucous  membrane  of  the 
bowels,  producing  diarrhoea.  When  the  tubercles  be- 
come sufficiently  developed  to  produce  inflammation  in 
that  portion  of  the  lung  surrounding  them,  the  pain 
and  stricture  in  the  chest  are  usually  increased.  The 
adhesive  inflammation  which  causes  the  pleura  pulmo- 
nalis and  pleura  costalis  to  unite,  causes  pain  in  the  cor- 
responding portion  of  the  chest.  Pains  of  a neuralgic 
character  also  not  unfrequently  attend,  and  are  felt,  not 
only  in  the  thorax,  but  in  the  sides,  shoulders,  back,  and 
other  parts  of  the  system.  The  hectic  fever,  sometimes 
preceded  by  a chill,  which  usually  comes  on  in  the  after- 
noon ; the  profuse  perspirations,  cough,  difficult  breath- 
ing, emaciation,  swelling  of  the  feet  and  ankles,  wan  fea- 
tures, sunken  eyes,  &c.  &c.,  need  scarcely  be  mentioned 
here,  as  they  are  usually  well  known  and  observed  by 
most  persons. 


CONSUMPTION— PHYSICAL  SIGNS. 


109 


Physical  Signs. — A full  consideration  of  the  physical 
signs  in  consumption,  would  occupy  too  much  room  in 
this  volume.  The  attention  we  have  given  to  phthisis 
in  general,  is,  indeed,  a digression,  in  part,  from  the 
main  subject  of  the  work;  but  desirous  to  give  con- 
densed information  on  the  subject  of  tuberculosis — and 
consumption,  one  of  its  frequent  forms — I hope  this  in- 
formation will  not  only  be  acceptable  to  the  reader,  but 
of  incalculable  interest  and  profit.  Those  who  wish  to 
study  the  physical  signs  more  fully,  I would  refer  to  works 
which  treat  of  it  more  at  length. 

Definition. — “ By  the  physical  signs  of  the  healthy  or 
diseased  condition  of  the  contents  of  the  thorax,  we  mean 
the  evidences  that  are  afforded  to  the  senses,  uninflu- 
enced by  the  vital  properties  of  those  contents ; in  con- 
tradistinction to  symptoms , which  are  the  evidences  af- 
forded by  the  living  contents  in  action.”  ( D-unglison .) 

These  are  principally  appreciated  by  means  of  auscul- 
tation and percussion.  Auscultation  is  the  means  by 
which  we  ascertain  the  healthy  or  diseased  condition  of 
the  organs  within  the  thorax,  &c.,  by  listening;  either 
with  the  ear,  applied  directly  to  the  outer  walls  of  the 
chest  ( immediate  auscultation ),  or  by  the  intervention 
of  the  stethoscope  ( mediate  auscultation).  Percussion, 
strictly  speaking,  is  a sort  of  auscultation,  a means  of 
eliciting  sounds  which  indicate  a healthy  or  diseased  con- 
dition, by  striking  the  chest;  either  with  the  fingers,  the 
tips  being  placed  on  a level,  or  by  some  instrument 
which  answers  the  same  purpose.  Percussion  may  be 
immediate , that  is,  by  striking  the  chest  directly;  or  it  may 
be  mediate,  that  is,  by  placing  a finger  of  the  left  hand 
transversely  and  flat  on  the  chest,  with  the  palmar  sur- 
face next  to  it,  or  by  the  intervention  of  a flat  piece  of 
ivory  or  metal,  laid  and  held  flat  on  the  chest ; and  strik- 
ing it,  either  with  the  tips  of  the  fingers  of  the  right  hand, 


110 


CONSUMPTION— PHYSICAL  SIGNS. 


or  an  instrument  made  for  the  purpose.  The  instrument 
which  is  placed  on  the  chest  is  called  a pleximeter,  and 
the  one  used  for  striking,  a plexor. 

Though  we  are  told  that  some  of  the  abnormal  sounds 
in  some  pulmonary  affections  did  not  even  escape  the  at- 
tention of  Hippocrates,  yet  the  diseases  of  the  organs 
contained  within  the  thorax  were  not  well  understood 
till  of  recent  date.  For  this  improvement  the  world  is 
indebted  to  the  distinguished  Frenchman,  M.  Laennec. 

Of  course,  in  order  to  properly  appreciate  the  sounds 
indicative  of  disease,  we  should  be  acquainted  with  the 
normal  or  healthy  sounds,  the  respiratory  or  vesicular 
murmur  ; discovered  by  auscultating  a part  of  the  chest 
corresponding  with  any  portion  of  the  lungs — being 
more  intense  and  prolonged  in  inspiration,  and  much 
more  audible  in  children  than  in  adults;  hence  called 
puerile — and  the  clear  hollow  sound  elicited  by  percus- 
sion. A knowledge  of  diseases  of  the  heart  is  also  ob- 
tained by  auscultation  and  percussion.  In  pregnancy, 
after  the  fifth  month,  auscultation  discovers  the  pulsa- 
tions of  the  foetal  heart — affording  indubitable  evidence 
of  this  condition ; at  the  same  time  assuring  us  that  the 
foetus  is  alive. 

The  physical  signs  of  phthisis  pulmonalis  may  be  con- 
sidered under  two  divisions  : 1st,  while  the  tubercles  are 
still  in  their  crude  state , or  before  softening  has  taken 
place ; and  2dly,  the  period  of  excavation , after  softening 
of  the  tubercular  matter  has  taken  place,  and  one  or  more 
cavities  are  formed  in  the  lung  or  lungs. 

1st.  Tubercles  are  commonly  deposited  in  the  apex  or 
upper  portion  of  one  or  both  lungs;  usually  to  a greater 
extent  in  one  lung  than  the  other — and  over  these  re- 
gions, as  between  the  clavicle  or  collar  bone  and  the  nip- 
ple, when  the  tubercular  deposition  is  sufficient,  percus- 
sion elicits  a dull  sound ; clearness  of  sound  diminishing 


CONSUMPTION— PHYSICAL  SIGNS. 


Ill 


as  the  tubercular  deposition  increases,  till  the  dull  sound 
is  completely  manifest.  On  auscultation,  the  respiratory- 
murmur  will  be  found  to  be  weak,  suppressed,  less  full 
and  free — while  in  the  sound  portions  of  the  lung  it  will 
be  puerile,  increased,  more  distinct;  expiration  more 
audible ; or,  as  Professor  L.  M.  Lawson  expresses  it, 
expiration  “ prolonged  and  intense;  slight,  dry,  crackling 
sound  ;.  occasionally  mucous  rhonchi;  more  or  less  bron- 
chial respiration  and  cough,  and  bronchophony ; vibra- 
tion of  the  voice  increased.” 

2d.  After  softening  of  the  tuberculous  matter  has  taken 
place,  and  one  or  more  cavities  formed,  percussion  still 
elicits  a sound  more  or  less  dull;  being  clearer,  accord- 
ingly as  they  are  larger,  nearer  the  surface,  and  the  less 
the  tubercular  deposit  in  the  adjacent,  surrounding,  or 
intervening  parts.  When  the  cavity  is  large  and  near 
the  surface,  the  sound  will  be  clear.  Auscultation  in- 
forms us  that  in  certain  portions  of  the  lung  there  is  no 
vesicular  respiration,  whilst  in  the  larger  bronchia  the 
respiration  may  be  considerably  louder  than  natural. 
The  mucous,  crepitant,  and  cavernous  rhonchi  may  be 
heard.  Cavernous  respiration,  which  occurs  when  air 
enters  a cavity  that  is  partially  or  entirely  empty,  may 
also  be  heard,  being  more  manifest  the  larger  the  cavity 
and  the  nearer  it  is  to  the  surface ; the  hollow  or  cavern- 
ous cough  is  manifest ; and  pectoriloquy  may  be  heard, 
being  more  distinct  when  the  cavity  is  large  and  near  the 
surface,  and  the  less  pus  or  matter  it  contains.  When  a 
cavity  is  Very  large,  and  sound  is  made  on  respiration 
analogous  to  that  produced  by  blowing  into  a flask  or 
bottle,  it  is  said  to  be  amphoric ; when  the  cavern  or 
abscess  extends  so  as  to  communicate  with  the  cavity  of 
the  thorax,  forming  a communication  between  the  bron- 
chia and  cavity  of  the  chest,  producing  pneumothorax — 
a sound,  according  to  Laennec,  like  that  induced  by 


112 


CONSUMPTION— THORACIC  VIBRATION. 


striking  metal,  glass,  or  porcelain,  with  a pin,  or,  accord- 
ing to  Professor  Dunglison,  “ more  like  the  sound  of  the 
keys  of  a “ musical  snuff  box,”  is  produced — called 
“ metallic  tinkling .”  Dunglison  says,  it  “is  heard  on 
causing  the  patient  to  speak  or  breathe,  but  is  more  dis- 
tinct when  he  coughs.  When  the  phenomenon  is  not  so 
strongly  marked,  it  produces  only  the  metallic  reson- 
ance.” 

As  to  the  cause  of  these  different  sounds,  Professor  L. 
M.  Lawson  briefly  remarks,  that  “ the  dull  sound,  and 
the  weak  respiratory  murmur,  are  produced  by  the  tu- 
bercular deposit  displacing  air ; mucous  rhonchi  depend 
on  the  presence  of  bronchitis;  the  crepitating  rhonchi  on 
inflammation;  cavernous  rhonchi  are  produced  by  air 
entering  a cavity  containing  fluid ; cavernous  respiration 
occurs  when  air  enters  a cavity  partially  or  entirely  empty. 
Bronchophony,  bronchial  cough  and  respiration,  depend 
on  consolidated  lung.” 

Thoracic  Vibration,  very  recently,  by  M.  Monneret, 
appears  to  be  made  more  available  and  of  more  extensive 
application,  as  a means  of  diagnosis,  than  any  notice  I 
have  heretofore  seen  ; and  though  the  following  extract 
is  not  alone  applicable  to  consumption,  it  may  be  of  in- 
terest to  the  reader,  as  applicable  to  this  and  other  tho- 
racic diseases. 

“ By  the  term  ‘ thoracic  vibration ,’  M.  Monneret  de- 
signates the  oscillation  of  the  parietes  of  the  chest,  per- 
ceptible by  the  application  of  the  hand  upon  ftie  thorax 
of  a person  who  sings  or  speaks  aloud.  The  vibrations 
are  more  distinct  in  the  right  side  than  in  the  left, — and 
in  the  anterior  than  in  the  posterior  regions.  The  vibra- 
tion is  propagated  from  the  larynx,  by  the  walls  of  the 
air  tubes,  by  the  solid  elements  of  the  thoracic  parietes, 
and  by  the  air  contained  in  the  lungs.  The  larynx  is 


CONSUMPTION— THORACIC  VIBRATION. 


113 


the  sonorous  instrument,  and  the  phenomena  perceptible 
by  the  application  of  the  hand,  are  caused  by  the  propa- 
gation of  the  undulations  of  sound,  through  the  agency 
of  good  conductors.  By  disease  of  the  chest,  the  physi- 
cal. conditions  of  these  conductors  being  modified,  the 
pectoral  vibrations  undergo  changes,  which  Dr.  Mon- 
neret  has  studied  for  the  purpose  of  discriminating  from 
each  other  the  various  alterations  of  the  respiratory 
organs. 

“ The  vibration  is  increased  in  pneumonia,  and  first 
stage  of  consumption ; it  is  diminished  in  pleurisy,  em- 
physema, and  pulmonary  excavation's. 

“ In  pneumonia,  thoracic  vibration  is  invariably  in- 
creased, and  to  that  degree,  that  even,  when  the  signs 
furnished  by  auscultation  and  percussion  are  still  of  a 
doubtful  nature,  a positive  diagnosis  may  be  obtained — 
a circumstance  peculiarly  advantageous  in  the  diseases 
of  infancy,  when  auscultation  is  difficult,  and  its  results 
questionable.  The  phenomena  of  vibration  are  also  in- 
creased in  pulmonary  oedema — a fact  testified  in  the  last 
stages  of  disorders  of  the  heart.  In  the  first  period  of 
consumption,  when  the  lung  is  condensed  by  the  presence 
of  crude  tubercular  masses,  it  often  happens,  that  auscul- 
tation furnishes  only  negative  signs,  or  increased  rough- 
ness of  the  respiratory  murmur,  so  slight  as  to  leave  some 
hesitation  in  the  mind  of  the  observer.  ‘ In  such  cases,’ 
says  Dr.  Monneret,  ‘ the  diagnosis  is  powerfully  assisted 
by  the  application  of  the  hand,  whilst  the  patient  speaks 
aloud — the  vibration  being  invariably  increased  in  the 
diseased  regions.  Again,  in  pleurisy,  attended  with  the 
formation  of  plastic  adhesions  and  false  membranes,  no 
fluid  being  exuded  between  the  Inns'  and  the  thoracic 
wails,  the  vibration  caused  by  the  voice  is  considerably 
augmented.’ 

“ It  is,  on  the  contrary,  diminished  or  abolished  in 


114 


CONSUMPTION— PATHOLOGY  OF  TUBERCULOSIS. 


pleurisy,  when  liquid  effusion  has  taken  place.  The  in- 
crease or  diminution  of  the  morbid  secretions  are  also 
marked  by  corresponding  modifications  in  the  transmis- 
sion of  sound  to  the  hand.  In  pulmonary  excavations  of 
some  extent,  the  vibration  of  voice  is  increased  or  alto- 
gether abolished ; but,  on  the  margin  of  the  cavities,  it 
is,  on  the  contrary,  increased  by  the  condensation  of  the 
lung  around  the  ulceration.  In  pneumothorax,  Dr.  Mon- 
neret  had  four  times  occasion  to  study  the  vibrations  of 
the  walls  of  the  chest,  and  in  all  the  cases  he  found  them 
abolished  in  the  regions  corresponding  to  those  occupied 
by  the  effusion  of  air.  In  pulmonary  emphysema,  also, 
the  undulations  of  sound,  perceptible  to  the  hand,  are  di- 
minished— a fact  easily  accounted  for  by  the  rarefaction 
of  the  tissue  of  the  lungs. 

‘‘Thus,  the  study  of  the  vibration  of  the  thoracic  walls 
can  be  made  available  in  the  diagnosis  of  doubtful  cases, 
and  forms  a valuable  addition  to  the  other  physical  signs 
of  thoracic  disease.  Med.  Times , from  Revue  Med.-Chi- 
rurgicale , Sept,  and  Oct.  1848.”  See  Amer.  Jcurn.  Med. 
Sci.,  Jan.  1849. 

Pathology  of  Tuberculosis  and  Consumption,  the 
latter,  as  before  remarked,  being  one  form  or  modification 
of  the  former.  The  erroneous  opinions  that  have  here- 
tofore prevailed,*  on  account  of  a want  of  knowledge 
of  the  correct  pathology  of  tuberculosis,  and  especially 
that  form  called  phthisis  pulmonalis,  or  consumption, 
may,  in  a great  measure,  explain  the  reason  why,  or  be 
offered  as  an  apology  for,  the  want  of  success,  heretofore, 

* And,  I may  add,  even  yet.  And  may  we  not  expect  that  improve- 
ment in  this  department  will  still  be  tardy,  and  rendered  more  so,  so  long 
as  such  prominent  and  influential  teachers  (who  stand  deservedly  high  as 
surgeons)  as  Professors  B.  W.  Dudley,  Gross,  and  others,  inculcate  and 
disseminate  erroneous  doctrines  on  this  subject? 


TUBERCULOUS  CACHEXIA. 


115 


in  the  treatment  of  the  different  modifications  of  this  form 
of  disease.  When  tubercular  matter  is  deposited  in  suf- 
ficient amount,  in  any  part  of  the  living  tissues,  it  acts  as  a 
foreign  substance,  producing  irritation  and  inflammation, 
which  latter  increases  the  deposition  of  the  tuberculous 
matter — hence,  it  has  heretofore  been  a common  error 
with  many,  and  is  with  some  yet  (the  early  deposit  of 
tubercular  matter  being  latent),  to  regard  the  tuberculous 
deposit  as  the  result  of  inflammation,  leading  to  the 
adoption  of  improper  treatment,  and,  of  course,  a conse- 
quent want  of  success.  Of  late  years,  microscopic  ex- 
aminations, and  the  investigations  in  animal  or  organic 
chemistry,  have  thrown  more  light  on  the  nature  of  this 
form  of  disease;  and  we  may  still  expect  our  knowledge 
increased  from  facts  derived  from  these  sources,  not 
only  in  relation  to  tubercular  diseases,  but  others.  As 
our  knowledge  of  morbid  processes  improves,  as  the  mi- 
croscope and  organic  chemistry  open  up  to  us  the  prima- 
ry alterations  producing  lesions  of  the  body,  when  pa- 
thology is  made  the  companion  of  physiology,  and  both 
constitute  the  foundation  for  a rational  system  of  thera- 
peutics,* then  may  we  hope  to  see  the  success  of  prac- 
tice corroborating  the  correctness  of  theory,  more  fully 
displayed,  and  medicine  relieved,  at  least  to  a great  ex- 
tent, of  empiricism. 

In  the  tuberculous  cachexia , the  general  health  is  more 
or  less  impaired,  the  tone  and  energies  of  the  vital  forces 
are  diminished,  the  actions  of  the  organs  of  nutrition  and 
assimilation  are  defective,  the  blood  is  in  an  abnormal 
condition,  more  or  less  analogous  to  what  it  is  in  the 
cachectic  conditions  we  have  already  noticed.  The  patho- 
logical condition  of  the  blood  has  been  too  much  neglected 
by  pathologists  in  this  form  of  disease.  Recently,  the 


* Beunet. 


116 


TUBERCULOUS  CACHEXIA. 


researches  of  M.  Andral  have  given  us  some  information 
on  the  condition  of  the  blood  in  this  and  other  diseases. 
Professor  Dunglison  says,  in  alluding  to  M.  Andral’s  re- 
searches, that  “ In  all  the  cases  of  incipient  tuberculosis, 
the  individual  was,  to  a certain  degree,  ansemic,  or  the 
blood  possessed  a modification  of  composition,  like  that 
which  belongs  to  feeble  constitutions,  or  those  in  which, 
owing  to  some  cause,  the  vital  forces  have  lost  their 
energy.  The  quantity  of  globules  was  diminished.  In 
proportion,  too,  as  the  tubercles  progressed,  the  diminu- 
tion of  the  globules  became  greater  and  greater,  and  when 
the  lungs  were  filled  with  caverns,  it  attained  its  mini- 
mum ; yet  this  diminution  was  never  as  great  as  in 
chlorosis.  M.  Andral  has  only  seen  a single  case  in 
which  the  proportion  of  globules  was  below  80  in  1000. 
In  every  other  case  it  oscillated  between  80  and  100.’’ 
The  amount  or  proportion  of  fibrin  is  said  to  be  normal, 
or  even  increased,  when  inflammation  and  fever  occurs; 
though  probably  it  is  abnormal  in  other  respects. 

We  have  already  noticed  the  nature  of  tuberculous 
matter.  In  whatever  part  of  the  body  it  is  deposited,  it 
would  seem  quite  clear  that  the  blood  must  furnish  the 
elements  of  it.  Dr.  Wright  says:  “Tubercular  matter 
may  be  found  either  in  the  blood-vessels,  or  externally  to 
them.  But,  wherever  tubercle  is  found,  the  blood  itself 
is  essentially  the  source  of  it.  In  those  cases,  numerous 
enough,  in  which  tubercle  is  discharged  abundantlv,  and 
in  a state  of  complete  maturation  from  the  mucous  mem- 
brane of  the  trachea,  or  bronchi,  or  bowels,  without  any 
lesion  of  these  parts,  such  matter  must  have  been  formed 
and  matured  in  the  circulating  system,  whence  it  was 
eliminated  as  a foreign  body  by  the  most  eligible  outlet.” 
I believe  the  most  prevalent  opinion  of  the  present  day, 
and  the  modern  phraseology  are,  that  in  the  tuberculous 
or  scrofulous  diathesis,  by  a 'perversion  of  the  ordinary 


TUBERCULOUS  CACHEXIA. 


117 


process  of  nutrition,  by  perverted  action , not  inflamma- 
tion, inorganizable  matter  (which,  we  have  seen,  is  mostly 
composed  of  albumen,  with  some  earthy  salts,  the  ele- 
ments of  which,  or  the  matter  itself,  being  already  formed 
in  the  blood)  is  deposited,  which,  in  a healthy  condition, 
would  have  taken  the  form  of  organized  fibrin.  To  Dr. 
Hughes  Bennet,  it  seems  certain,  that  in  tubercular  dis- 
eases and  chronic  rheumatism,  the  albuminous  com- 
pounds are  in  excess,  and  the  oily  compounds  diminished, 
in  the  economy. 

Dr.  Carpenter  says  : “ In  persons  of  that  peculiar  con- 
stitution which  is  termed  scrofulous,  or  strumous,  we  find 
an  imperfectly  organizable  or  cacoplastic  deposit,  or  even 
an  altogether  aplastic  product,  known  by  the  designation 
of  tubercular  matter,  frequently  taking  the  place  of  the 
normal  elements  of  tissue,  both  in  the  ordinary  process 
of  nutrition,*  and  still  more  when  inflammation  is  set  up. 
From  an  examination  of  the  blood  of  tuberculous  sub- 
jects, it  appears  that  the  fibrinous  element  is  not  deficient 
in  amount,  but  that  it  is  not  duly  elaborated  ; so  that  the 
coagulum  is  loose,  and  the  red  corpuscles  are  found  to 
bear  an  abnormally  low  proportion  to  it.  We  can  under- 
stand, therefore,  that  such  a constant  deficiency  in  the 
plasticity,  must  affect-  the  ordinary  nutritive  process,  and 
there  will  be  a liability  to  the  deposit  of  cacoplastic  pro- 
ducts without  inflammation,  instead  of  the  normal  ele- 
ments of  tissue.  Such  appears  to  be  the  history  of  the 
formation  of  tubercles  in  the  lungs,  and  other  organs, 
when  it  occurs  as  a kind  of  metamorphosis  of  the  ordi- 

* Dr.  Carpenter  is  certainly  in  error,  in  saying  that  tubercular  matter 
may  be  deposited  “ in  the  ordinary  process  of  nutrition,”  for  the  process 
must  certainly  be  a morbid  one  ; and  Dr.  C.  shortly  after  contradicts  him- 
self. He  may,  however,  here  mean,  that  the  process  is  not  recognized  by 
us,  that  it  is  latent,  and  the  tubercular  matter  deposited  before  we  are 
aware  of  it. 


118 


CONSUMPTION— PATHOLOGY. 


nary  nutritive  process;  and  in  this  manner  it  may  pro- 
ceed insidiously  for  a long  period,  so  that  a large  part  of 
the  tissue  of  the  lungs  shall  be  replaced  by  an  amorphous 
deposit,  without  any  other  ostensible  sign  than  an  in- 
creasing difficulty  in  respiration.  It  is  in  the  different 
forms  of  tubercular  deposit,  that  we  see  the  gradation 
most  strikingly  displayed  between  the  plastic  and  aplastic 
formations.  In  the  semi-transparent,  miliary,  gray,  and 
tough  yellow  forms  of  tubercle,  we  find  traces  of  organi- 
zation in  the  form  of  cells  and  fibres  more  or  less  obvious ; 
these  being  sometimes  almost  as  perfectly  formed  as  those 
of  plastic  lymph,  at  least  on  the  superficial  part  of  the 
deposit,  which  is  in  immediate  relation  with  the  living 
structures  around,  and  sometimes  so  degenerated  as 
scarcely  to  be  distinguishable.  In  no  instances  do  such 
deposits  ever  undergo  further  organization,  and,  there- 
fore, they  must  be  regarded  as  cacoplastic.  But  in  the 
opaque,  crude,  and  yellow  tubercle,  we  do  not  find  even 
these  traces  of  definite  structure,  for  the  matter  of  which 
it  consists  is  altogether  granular,  more  resembling  that 
which  we  find  in  an  albuminous  coagulum.  The  larger 
the  proportion  of  this  kind  of  matter  in  a tuberculous 
deposit,  the  more  it  is  prone  to  soften,  whilst  the  semi- 
organized  tubercle  has  more  tendency  to  contraction. 
This  is  entirely  aplastic.  Now,  although  tubercular 
matter  may  be  slowly  and  insidiously  deposited  by  a 
kind  of  degradation  of  the  ordinary  nutritive  process, 
yet  it  cannot  be  doubted  that  inflammation  has  a great 
tendency  to  favor  it,  so  that  a larger  quantity  may  be 
produced  in  the  lungs  after  a pneumonia  has  existed  for 
a day  or  two,  than  it  would  have  required  years  to  gene- 
rate in  the  previous  mode.  But  the  character  of  the 
deposit  still  remains  the  same,  and  its  relations  to  the 
plastic  elements  of  the  blood  are  shown  by  the  interesting 
fact,  of  no  unfrequent  occurrence,  that  in  a pneumonia 


CONSUMPTION— PATHOLOGY. 


119 


affecting  a tuberculous  subject,  plastic  lymph  is  thrown 
out  in  one  part,  whilst  tuberculous  matter  is  deposited  in 
another.  Now  inflammation,  producing  a rapid  deposi- 
tion of  tubercular  matter,  is  peculiarly  liable  to  arise  in 
organs  which  have  been  previously  affected  with  chronic 
tubercular  deposits,  which,  acting  like  foreign  bodies,  may 
of  themselves  become  sources  of  irritation ; and  the  per- 
version of  the  structure  and  functions  of  the  part  renders 
it  peculiarly  susceptible  of  the  influence  of  external 
morbific  causes.  These  views,  at  which  several  recent 
physiologists  and  pathologists  have  arrived  on  independent 
grounds,  seem  to  reconcile  or  supersede  all  the  discordant 
opinions  which  have  been  upheld  at  different  times,  re- 
garding the  nature  of  tubercle  ; and  lead  to  the  soundest 
views  with  respect  to  the  treatment  of  the  diathesis/’ 

Dr.  Harden,  after  investigating  the  subject,  and  making 
the  above  long  quotation,  remarks  : “ Having  now  ex- 
plained, as  far  as  we  are  able,  the  nature  and  origin  of 
tubercle,  or  strumous  matter,  which  we  believe  identical, 
we  lay  down  the  following  proposition  : that,  namely,  in 
whatever  part  of  the  system  this  matter  may  be  found 
deposited,  however  variant  may  be  the  symptoms  pro- 
duced from  the  functions  disturbed,  the  diseases  by  which 
this  deposit  was  effected,  are  invariably  the  same,  or,  in 
other  words,  are  isopathic  in  their  nature.  This  proposi- 
tion is  fully  established  if  the  law,  which  we  have  already 
laid  down,  be  admitted  to  be  true,  namely,  that  ‘ diseases 
which  result  in  products,  or  deposits,  which  are  both 
isomorphic  and  isomeric,  must  be  considered  as  isopathic, 
no  matter  how  they  may  differ  in  their  seats  and  symp- 
toms.’ ” 

Does  it  not  seem  rather  remarkable,  that  some  are  so 
illogical  as  to  consider  the  different  modifications  of  tu- 
bercular disease  as  so  many  distinct  diseases,  because 
the  tuberculous  matter  happens  to  be  deposited  in  some 


120 


CONSUMPTION— PATHOLOGY. 


cases  in  one  part  of  the  body,  and  in  others  in  other  parts  ? 
In  syphilis,  if  in  one  case  an  ulcer  should  appear  in  the 
groin,  or  a node  on  the  shin  bone,  and  in  another  case  an 
ulcer  should  form  in  the  throat,  or  the  superior  maxillary 
be  affected,  or  spots  on  the  skin,  would  they  be  regarded 
as  different  diseases?  Or  in  rheumatism,  because  in  one 
case  the  knee  should  suffer,  and  in  another  the  elbow  or 
heart?  Or,  indeed,  any  other  constitutional  disease,  which 
may  at  one  time  exhibit  certain  local  phenomena  in  one 
place  and  then  again  in  another?  We  have  already  re- 
ferred to  some  authors  who  tell  us  the  chief  ingredient  in 
tubercle  is  albumen,  and  that  the  chief  ingredient  of  scro- 
fulous matter  i$  albumen  too.  M.  Laennec  says  : “Tu- 
bercles in  the  lungs  differ  in  no  respect  from  those  situated 
in  the  glands,  and  which,  under  the  name  of  scrofula, 
after  being  softened  and  evacuated,  are  followed  by  a 
perfect  cure.”  Mr.  Gulliver  says,  that  “ crude  tubercular 
matter,  from  whatever  organ  obtained , differs  as  little  in 
its  microscopical  as  in  its  general  and  chemical  characters. 
The  drawing  shows  how  nearly  the  microscopical  ele- 
ments composing  crude  tubercles  of  the  lungs  and  of  the 
lymphatic  glands  agree”  Lugolsays:  “ The  identity  of 
scrofula  and  pulmonary  tubercles  is,  in  our  opinion,  most 
manifest ;”  and  further  remarks,  that  “the  natural  death 
of  the  scrofulous , is  by  consumption  ; we  might  say,  in- 
deed, that  they  seldom  die  in  any  other  way,  for  in  all 
forms  of  scrofula,  death  rarely  takes  place  until  after  the 
invasion  of  the  lungs  by  tubercular  deposit.”  It  appears 
that  Dr.  Glover  is  a believer  in  the  identity  of  scrofula 
and  tubercle.  I might  quote  other  authors  on  this  sub- 
ject, but  will  close  this  part  of  it  by  the  following  quota- 
tion from  the  reviewer  of  Dr.  Gibert’s  work  on  pulmonary 
consumption.  “ These  seeds  (that  is,  of  unorganizable 
matter)  are  generally  known  by  the  name  of  tubercular 
matter,  and  when  deposited  in  the  lungs  in  separate 


CACHEXIA— TREATMENT  OF. 


121 


masses,  they  are  termed  tubercles,  and  the  resulting  dis- 
ease is  denominated  consumption  of  the  lungs.  It  may, 
however,  be  here  observed,  that  where  tubercular  or 
unorganizable  matter  becomes  deposited  in  any  of  the 
lymphatic  glands  or  in  the  joints,  the  disease  is  termed 
scrofula.  If,  on  the  other  hand,  it  is  arrested  in  its  pas- 
sage through  the  mesenteric  glands,  then  the  name  of 
tabes  mesenterica  is  employed  to  distinguish  it.  It  must, 
therefore,  appear  obvious  that  these  three  diseases  are  all 
radically  one  and  the  same , depending  entirely  on  the 
presence  of  unorganizable  matter,  and  differing  only  in 
locality ” 

Treatment. — We  come  now  to  speak  of  the  treatment 
of  the  different  modifications  of  cachexia  which  we  have 
noticed,  and  which  require  the  same  general  principles 
of  treatment,  with  some  modifications  adapted  to  each 
form.  We  may  observe  with  regret,  that  though  authors 
have  mentioned,  in  general  terms,  the  principles  which 
should  be  our  guide  in  the  treatment  of  this  family  of 
diseases,  yet  in  the  detail  they  have  departed  widely 
from  them,  especially  with  regard  to  consumption.  Wre 
have  paid  some  attention  to  the  pathology  of  these  af- 
fections, and  should  resort  to  the  means  best  calculated 
to  remedy  these  morbid  conditions ; to  improve  the  con- 
dition of  the  blood,  to  increase  and  improve  the  blood- 
globules,  etc  ; to  impart  energy  to  the  vital  forces,  to  the 
functions  of  assimilation  and  nutrition,  to  increase  the 
tone  and  vigor  of  the  system,  to  change  the  diathesis, 
or  morbid  condition,  and  bring  it  to  a healthy  one,  as  well 
as  to  remedy,  if  possible,  the  organic  or  local  morbid  con- 
ditions which  are  produced  by  the  different  forms  of 
cachexia,  and  which  are  emphatically  constitutional.  In 
order  that  these  indications  may  be  fulfilled,  it  is  im- 
portant that  every  rational  mind  interested  should  be 
9 


122 


CACHEXIA— TREATMENT  OF. 


impressed  with  the  importance  of  time  and  perseverance 
— and  it  would  be  well  for  physicians  to  explain  these 
things,  as  well  as  they  can,  to  those  who  seek  their  pro- 
fessional advice,  in  order  that  they  may  be  induced  to 
continue  the  treatment  which  is  the  only  earthly  haven 
of  safety  to  them — and  also  that  they  may  not  lose  confi- 
dence in  the  capability  of  their  medical  adviser,  and  fly 
from  one  to  another,  and  to  every  remedy  that  is  recom- 
mended by  friends,  to  patent  nostrums,  which,  on  ac- 
count of  the  opiates  they  contain,  may  induce  the  patient 
for  a short  time  to  believe  he  is  better;  but  which  con- 
fidence is  illusive,  and  only  calculated  to  add  to  the 
morbid  condition.  Important  time  is  thus  also  lost,  and 
the  disease  is  rendered  more  fatal. 

To  carry  out  and  fulfil  the  above  indications,  the 
ferruginous  preparations,  the  cod-liver  oil,  and  proper 
adjuvantia,  with  a variety  of  generous  and  nourishing 
diet,  and  other  hygienic  means  calculated  to  improve 
the  tone  and  vigor  of  the  system,  are  decidedly  and  un- 
questionably superior  to  all  other  means  yet  known.  Is 
it  not  remarkable  that  European  and  our  own  hyperbo- 
rean authors,  having  witnessed  the  successful  influence 
of  different  preparations  of  iron  in  chlorosis  (; green  sick- 
ness), should  not  have  been  led  to  its  more  general 
exhibition  in  the  kindred  cachexia?  Though  I have 
mentioned  cod-liver  oil  in  connection  with  iron,  it  is 
proper  to  remark  that  its  therapeutic  value  is  not  yet  so 
well  ascertained.  Recently,  it  appears  to  be  attracting 
more  attention  than  formerly.  We  will  notice  it  more 
particularly  after  a while.  In  the  different  cachectic 
conditions,  the  preparations  of  iron  act  as  powerful 
tonics,  improve  the  blood,  increase  the  blood-globules, 
change  the  features  from  a pale,  sickly  aspect,  causing 
them  to  present  the  florid  appearance  of  health.  In 
order  to  be  more  certain  in  securing  these  effects,  or  to 


CACHEXIA— TREATMENT  OF. 


123 


contribute  to  the  favorable  influence  of  the  preparations 
of  this  metal,  it  is  of  importance  to  combine  corrigents, 
or  stimulants,  or  stimulant  tonics,  with  them.  It  may 
be  well  to  use  one  preparation  for  a few  weeks,  and  then 
alternate  with  another,  using  the  latter  about  the  same 
length  of  time  as  the  former,  then  resuming  the  former 
again,  or  using  some  other  preparation  of  this  metal. 
The  subcarbonate  of  iron  may  be  mixed  wdth  pulverized 
capsicum  (Cayenne  pepper),  myrrh,  or  seneca  snake- 
root,  etc.  etc.,  with  the  addition,  if  necessary,  of  a small 
portion  of  pulverized  rhubarb,  to  avoid  costiveness.  The 
following  formula  may  answer  this  purpose  : — 

R.  Sub.  carb.  iron  sis  to  ten  draclnns  ; 

Capsicum,  pulv.  two  to  three  drachms  ; 

Rhubarb,  pulv.  two  to  four  drachms. 

Mix  well,  by  rubbing  together  in  a mortar.  Dose,  from 
fifteen  to  twenty  grains,  wrhich  may  be  gradually  in- 
creased, if  necessary,  three  times  a day ; and  may  be 
conveniently  taken  in  syrup  of  any  kind,  molasses,  or 
moistened  with  a little  brandy,  wine,-  or  whisky.  Or, 
the  above  powders  may  be  made  into  pills  with  some 
tonic  vegetable  extract;  as  the  extract  of  gentian,  or  Pe- 
ruvian bark.  If  the  pulverized  bark  of  the  root  of  the 
seneka  ( Polijgcila  senega ) be  used  in  the  above  formula 
instead  of  the  pepper,  five  drachms  or  more  may  be  added. 
If  there  is  no  costiveness,  the  rhubarb  should  be  left  out, 
or  used  in  smaller  quantity.  Pills  made  of  the  sulphate 
of  iron  (copperas),  pulverized  capsicum  or  seneka,  and 
extract  of  gentian  or  barks,  may  be  alternated  with  the 
above,  every  wreek  or  two.  They  may  be  made  as  fol- 
lows : — 

R . Sulphate  of  iron  two  drachms ; 

Cayenne  pepper,'  pulv.  two  drachms,  or, 

Seneka  one  and  a-half  ounces ; 

Extract  gentian  four  drachms. 


124 


CACHEXIA— TREATMENT  OP. 


Make  into  one  hundred  and  twenty  pills;  dose,  three  of 
them,  thrice  daily. 

Pills  of  carbonate  of  iron,  sometimes  called  Yallet’s 
ferruginous  pills,  are  considered,  by  some  authors,  as  being 
superior  to  all  other  preparations  of  this  metal; — from 
three  to  five  grains  of  the  ferruginous  mass  being  a dose, 
which  may  be  taken  three  times  a day;  the  dose  may 
be  increased,  so  that  twenty-five  or  thirty  grains  may  be 
taken  in  the  course  of  the  day.  The  influence  of  this 
preparation  would,  no  doubt,  be  much  improved  by  the 
addition  of  some  stomachic,  corrigent,  or  stimulant;  as 
capsicum,  seneka,  myrrh,  &c.  &c.  This  preparation,  or 
Vallet’s  ferruginous  pills,  have  been  very  highly  spoken 
of  as  being  successful  in  the  treatment  of  chlorosis.  Dr. 
Bache  says,  “ It  is  considered  particularly  useful  in 
chlorosis,  amenorrhcea,  and  other  female  complaints,  and 
appears  to  act  favorably  by  increasing  the  coloring  mat- 
ter of  the  blood,  causing  the  capillary  system  to  become 
more  fully  injected,  and  the  lips  to  assume  a redder  co- 
lor.” Bland’s  pills  are  also  favorably  spoken  of  in  simi- 
lar conditions  of  the  system,  especially  chlorosis. 

In  that  modification  of  these  cachexse  called  scrofula, 
the  syrup  of  iodide  of  iron  may,  occasionally,  be  alter- 
nated with  the  other  preparations  of  iron,  in  doses  of  from 
fifteen  to  thirty  or  forty  drops,  taken  three  times  a day, 
in  half  a glass  of  sweetened  water.  If  it  should  unplea- 
santly affect  the  stomach,  a piece  of  starch,  biscuit,  or 
bread,  may  be  eaten  immediately  after  taking  it;  or  it 
should  be  discontinued.  According  to  the  writer's  ex- 
perience  and  observation,  the  preparations  of  iodine,  so 
far  as  he  has  used  them,  or  seen  them  used,  solely  relied 
on  as  therapeutic  agents,  are  not  only  ineffectual  in  the 
different  forms  of  cachexia,  but  are  not  unfrequently  ab- 
solutely detrimental.  Iodine  seems  better  adapted  to  the 
scrofulous  form  than  any  other, — and  the  iodide  of  iron 


CONSUMPTION — TREATMENT  OF. 


125 


I believe  is  the  best  form  in  which  to  exhibit  it,  as  above 
directed.  M.  Negrier  speaks  highly  of  different  prepa- 
rations of  the  leaves  of  the  walnut  tree  ( Juglans  regia) ; 
and  especially  of  the  extract,  in  scropliulosis. 

If  iodine  is  given  in  anaemia , I believe  its  usual  effect 
is  to  increase  this  condition,  at  least  in  many  cases.  To 
a lady  that  was  moderately  anaemic , and  affected  with 
hepatalgia , I once  gave  iron  for  a time ; she  improved 
under  its  use ; but  before  the  cure  was  entirely  complete, 
I suspended  the  use  of  iron,  and  gave  iodine  for  a time, 
which  had  the  effect  of  increasing  the  anaemic  condition  ; 
or,  at  any  rate,  the  anaemia  and  hepatalgia  increased  dur- 
ing its  use.  I again  gave  subcarbonate  of  iron,  and  the 
improvement  was  soon  manifest.  In  splenic  cachexia , 
and  for  the  concomitant  enlargement  of  the  spleen,  iodine 
is,  I believe,  unfortunately  too  much  given.  From  ex- 
perience and  observation,  I feel  confident  that  it  seldom 
exercises  a favorable  influence  either  on  the  spleen  or  the 
cachectic  condition;  and  that  it  is  often  detrimental — to 
say  nothing  of  the  neglect  of  more  appropriate  remedies, 
and  the  loss  of  important  time. 

If,  during  the  treatment  of  any  of  the  forms  of  cachexia, 
aperients  should  be  needed  to  gently  open  the  bowels, 
the  extract  of  white  walnut  ( Juglans  cinerea),  or  the 
extract  of  dandelion  and  rhubarb,  answers  this  purpose 
very  well.  I may  here  mention,  that  the  use  of  the 
preparations  of  iron  gives  to  the  stools  a dark  or  black 
color. 

Phthisis  Pulmonalis,  or  Consumption — Treatment 
of. — In  the  treatment  of  this  form  of  cachexia,  the  pre- 
parations of  iron  should  be  given  as  recommended  above; 
and  it  is  important  in  this,  as  well  as  in  the  other  forms, 
that  attention  should  be  paid  to  it  sufficiently  early,  so 
that  this  diathesis  of  the  system  may  be  changed  to  a 


126 


CONSUMPTION— TREATMENT  OF. 


healthy  condition  before  the  disease  has  progressed  too 
far  in  its  onward  course.  When  tubercles  have  formed 
in  the  lungs,  it  is  thought  they  cannot  be  removed 
by  medicine  by  absorption;  but  if  they  are  as  yet  too 
small  to  produce  irritation  and  inflammation,  then  fur- 
ther deposition  and  development  may  be  arrested,  the 
individual’s  health  may  be  restored,  and,  under  favor- 
able circumstances,  his  or  her  life  may  be  very  little,  or 
not  at  all  shortened  thereby,  or  in  consequence  thereof. 
But  if  the  tubercular  deposit  has  accumulated  to  such  an 
extent  as  to  produce  inflammation  and  suppuration,  or 
abscess,  the  tubercles  become  softened  and  may  escape, 
as  is  usually  the  case,  through  the  bronchia  and  trachea, 
and  be  thrown  off  by  expectoration.  Under  favorable 
circumstances  and  proper  treatment,  the  abscess  in  the 
lungs  may  be  made  to  heal;  and  the  health  of  the  indi- 
vidual may  again  be  established.  But  when  large 
amounts  of  tuberculous  matter  are  deposited  in  different 
parts  of  the  lungs,  and  they  are  greatly  injured  by  cavi- 
ties, here  and  there,  a favorable  issue  or  termination 
need  not  be  expected  under  any  circumstances,  or  mode 
of  treatment. 

It  would  be  well  for  those  who  are  cachectic,  or  pre- 
disposed to  consumption,  if  they  could  be  made  to  under- 
stand the  importance  of  early  attention  to  this  condition, 
and  be  induced  to  resort  to,  and  persevere  in  the  use  of 
ferruginous  preparations,  as,  indeed,  a part  of  their  diet, 
till  this  diathesis  is  removed ; after  which,  they  may 
gradually  be  dispensed  with;  paying  particular  atten- 
tion, in  the  mean  time,  to  other  measures  calculated  to 
invigorate  the  system ; and  the  avoidance  of  those  which 
are  calculated  to  have  the  contrary  effect.  “ Some  ex- 
periments on  the  influence  of  different  agents,  in  pre- 
venting the  development  of  tubercles,  have  been  re- 
cently made,  by  M.  Coster,  and  the  details  thereof  laid 


CONSUMPTION— TREATMENT  OF. 


127 


before  the  Academie  Royale  de  Medeeine  of  Paris.  He 
experimented  upon  dogs,  rabbits,  Guinea  pigs,  and  fowls, 
which  he  subjected  to  the  most  injurious  hygienic  influ- 
ences; and  to  combat  these,  administered  iron,  baryta, 
iodine,  bromine,  mercury,  and  tannin.  The  agent  which 
always  succeeded  with  him,  in  the  prevention  of  tuber- 
cles, was  a ferruginous  bread,  composed  of  half  a drachm 
of  the  subcarbonate  of  iron  to  a pound  of  bread.  A 
quarter  of  a pound  of  the  bread  w*as  taken  in  the  day.”* 
Would  it  not  be  well  for  those  wdio  are  predisposed  to 
tuberculosis,  or  consumption,  to  profit  by  these  experi- 
ments? In  the  treatment  of  consumption,  perhaps  it 
would  be  well  to  give  some  of  the  preparations  of  iron, 
as  in  the  formulas  heretofore  given,  in  cod-liver  oil  ( oleum 
jecoris  aselli ).  Indeed,  since  the  publication  of  Dr. 
Hughes  Bennett’s  work  in  1841,  on  the  use  of  cod-liver 
oil  in  consumption,  it  appears  to  be  gaining  some  repu- 
tation for  the  treatment  of  this  disease.  Dr.  Bennett  was 
induced  to  give  cod-liver  oil  in  tubercular  diseases,  and 
chronic  rheumatism,  because  he  felt  certain  that  in  these 
diseases,  the  albuminous  compounds  were  in  excess, 
while  the  oily  compounds  were  diminished  in  the  eco- 
nomy; and  that  the  direct  addition  of  the  latter,  is  the 
rational  method  of  supplying  the  w^ants  of  the  system. 
A reviewer  of  Dr.  Bennett’s  work  says:  “It  operates  by 
imparting  to  the  system  one  of  the  great  elements  neces- 
sary for  the  nutrition  of  the  animal  economy,  in  cases 
w'here  that  element  is  essentially  defective.  In  the  hands 
of  the  rational  practitioner,  it  is  destined  to  be  an  im- 
portant means  of  curing  a class  of  diseases,  hitherto  con- 
sidered of  the  most  dangerous  and  fatal  nature.”  Dr. 
Bennett  says:  “The  effect  of  the  oil,  in  many  cases  of 
phthisis,  is  very  striking,  and  is  well  seen  in  hospital 


* See  Dunglison’s  Practice,  Vol.  I.  pp.  369,  370. 


128 


CONSUMPTION— TREATMENT  OF. 


and  dispensary  practice.  Individuals  presenting  ema- 
ciation, profuse  sweats,  constant  cough  and  expectora- 
tion, as  most  prominent  symptoms,  with  a degree  of 
weakness  that  prevents  their  standing  alone,  after  a few 
weeks  use  of  it  are  enabled  to  get  up  with  ease  and  walk 
about,  with  visible  improvement  in  their  general  health, 
and  an  increased  amount  of  flesh.  The  physical  signs  of 
the  disease  may  continue  unaffected  for  sometime;  but 
if  the  treatment  be  continued,  the  moist,  gurgling  rales 
are  exchanged  for  dry,  blowing  sounds,  which  become 
more  and  more  persistent,  pectoriloquy  is  merged  into 
bronchophony,  the  respiration  is  easier,  and  a check  is 
evidently  given  to  the  ulcerative  process,  and  the  forma- 
tion of  purulent  matter  in  the  air  passages.  In  this  state, 
patients  often  feel  themselves  so  well  that  they  insist  on 
leaving  the  hospital,  or  give  up  their  attendance  on  the 
dispensary.  Dr.  Bennett  has  frequently  found  it  impos- 
sible to  prevail  on  such  persons  to  continue  the  treatment, 
and  the  consequence  is,  that,  again  returning  to  their 
often  unhealthy  employment  and  bad  diet,  and  exposed 
to  the  other  causes  favorable  to  the  production  of  the 
disease,  the  distressing  symptoms  again  recur.  Several 
cases,  with  one  or  more  caverns  in  the  lungs,  have  in 
this  manner  returned  to  the  infirmary  from  four  to  seven 
or  eight  times,  during  the  last  six  years,  and  on  each 
occasion  have  gone  out  in  their  own  opinion  perfectly 
cured.  ”f 

As,  in  most  cases  of  consumption,  there  is  more  or  less 
dyspepsia,  especially  in  the  latter  stages,  which  renders 
the  stomach  irritable,  impairs  the  appetite,  often  prevents 
sufficient  nourishment  being  taken,  and  in  some  of  these 
cases  the  cod-liver  oil  cannot  be  retained  on  the  stomach, 

* Monthly  Journal  and  Retrospect,  VI ay  1848,  from  Bennett,  on  Cod-liver 
Oil.  Edinburgh,  1848.  Am.  Journ.  Med.  Sci.,  July  1848. 


CONSUMPTION— TREATMENT— COD-LIVER  OIL. 


129 


Dr.  Bennett  says  it  will  then  be  necessary  to  calm  the 
irritability  of  the  stomach,  and  the  best  remedy  for  this 
purpose,  according  to  his  experience,  is  naphtha. 

The  following  communication  to  the  editor  of  the 
American  Journal  of  the  Medical  Sciences , Dr.  Isaac 
Hays,  and  which  is  published  in  the  January  No.  of 
that  Journal,  1849,  may  add  further  encouragement  in 
the  use  of  the  cod-liver  oil.  The  communication  is  from 
J.  Young,  Ml  D.,  of  Chester. 

“The  following  case  is  thought  not  to  be  void  of  in- 
terest.  It  shows  that,  in  the  article  used,  we  have  an 
addition  to  our  resources  in  the  treatment  of  consumption, 
which  promises  more  success  than  any,  or  all  others,  in 
some  cases.  Certain  it  is,  that  the  case  about  to  be  de- 
tailed was  an  unpromising  one,  and  the  oleum  jecoris 
aselli  was  the  only,  or  the  first  article,  that  produced  the 
least  check  to  the  onward  progress  of  the  dire  invader. 

“ Mrs.  K.,  of  your  city,  a widow  lady,  of  a consump- 
tive family,  aged  forty -four  years,  visited  me,  last  May, 
for  advice.  She  had  had  a cough  for  fifteen,  or  more, 
months,  gradually  increasing  in  violence,  for  which  she 
had  tried  a great  variety  of  remedies,  with  but  little  or 
no  benefit.  She  had  had  various  medical  prescriptions, 
and  had  been  prevailed  on  to  try  homoeopathy.  She  had 
tried  many  of  the  quack  remedies,  such  as  syrup  of  wild 
cherry,  Jayne’s  expectorant,  the  syrup  of  tar  and  naphtha, 
&c.,  but  none  of  them  had  been  of  any  service.  Her 
appearance  was  pale  and  haggard  ; her  walk  exceedingly 
slow,  and  bowed  forward.  She  had  profuse  expectora- 
tion; exhausting  night  sweats  ; was  very  ‘ short  breathed,” 
and  coughed,  on  using  a little  exercise,  almost  inces- 
santly, with  occasional  hard  ‘ spells’  that  almost  ex- 
hausted her  ; her  appetite  wms  variable,  and  her  stomach 
dyspeptic;  her  pulse  was  110;  tongue  covered  with  a 
white  fur;  respiration  from  thirty -five  to  forty  in  a 


130 


CONSUMPTION— TREATMENT— COD-LIVER  OIL. 


minute.  Auscultation  revealed,  under  the  scapular  end 
of  the  left  clavicle  (collar  bone),  strongly  marked  bron- 
chophony, and  also  in  the  interscapular  space  the 
same,  though  less  strongly ; in  the  axilla,  pectoriloquy, 
with  a strong,  gurgling  rattle,  extending  over  a space  of 
two  or  two  and  a half  inches  square.  Below  this  zone 
was  another,  two  or  more  inches  in  depth,  with  no  vesi- 
cular murmur,  but,  instead,  a slight,  mucous  rattle,  par- 
ticularly when  she  coughed ; below  this  the  respiration 
was  clear,  as  it  was  for  some  space  under  the  sternal  por- 
tion of  the  clavicle.  The  right  lung  was  sound. 

“ Under  this  state  of  affairs  I thought  it  almost  useless 
to  prescribe  anything.  There  was,  however,  one  encour- 
aging symptom,  she  menstruated  regularly,  and  while 
this  is  the  case,  I always  entertain  some  hope,  no  matter 
how  unpromising  other  things  may  be.  I first  truncated 
a portion  of  the  uvula,  as  it  was  much  elongated.  This 
had  the  effect  of  relieving,  at  once,  the  strangling  spells 
of  cough.  She  was  requested  to  take  Hasting’s  wood 
naphtha,  commencing  with  twenty  drops  three  times  a 
day,  in  simple  syrup,  with  five  drops  of  McMunn’s  elixir 
in  each.  This  was  gradually  increased  till  she  took  forty- 
five  drops  three  times  a day.  In  five  weeks  she  was  not 
benefited  in  the  smallest  degree,  while  her  strength  had 
deteriorated  materially.  She  now,  successively,  tried 
every  variety  of  cough  mixtures,  comprising  the  tere- 
binthinate  and  balsamic  preparations,  but  all  were  of  no 
benefit.  Her  menstrual  period  went  by  in  June,  without 
any  show.  By  the  last  of  July,  her  strength  was  so  far 
gone,  and  her  symptoms  progressing  so  rapidly,  that  she 
gave  up  her  house  in  the  city,  and  came  to  Chester  for 
the  benefit  of  country  air,  and  to  escape  from  the  cares  of 
housekeeping. 

“ Her  situation  at  that  time  was,  extreme  emaciation  ; 
the  eyes  sunk  and  dark  under  them  ; complexion  sallow  ; 


CONSUMPTION— TREATMENT— COD-LIVER  OIL. 


131 


pulse  120 ; stomach  rejects  almost  everything  ; no  appe- 
tite for  anything;  coughs  almost  half  the  time;  night 
sweats ; orthopnoea,  so  that  she  cannot  lie  below  an  angle 
of  forty -five  degrees;  sleeps  but  little;  has  chills  and 
fever,  sometimes  every  day  ; circumscribed  spots  in  the 
cheeks,  with  burning  of  hands  and  feet;  so  weak  she 
‘ can’t  wrnlk  fifty  yards ;’  unable  to  get  up  stairs  without 
assistance,  or  climbing  by  the  banisters,  and  stopping 
every  two  or  three  steps;  she  has  become  round 
shouldered  and  stooping. 

“The  stethoscopic  signs  are,  in  the  axilla,  extremely 
loud  and  tracheal,  or  cavernous  sounds,  with  a g-uro-linsr 
rattle  when  she  coughs,  or  endeavors  to  inspire  deeply ; 
pectoriloquy  quite  distinct;  anterior  to  this  is  mucous 
rattle,  with  bronchophony ; posteriorly  the  same,  but  less 
loud.  In  the  portion  immediately  under  this,  there  was 
more  of  a creeping,  mucous  rale  than  when  examined  pre- 
viously, and  slight  bronchophony,  the  remaining  portions 
unaffected,  or  but  slightly  so.  The  expectoration  at 
times  is  most  profuse,  particularly  if,  by  means  of  opiates, 
the  cough  is  quieted  partially  for  a few  hours ; is  mostly 
yellowish,  heavy,  and  sinks  in  water,  as  would  lead. 
Occasionally,  however,  for  a day  at  a time,  it  consists 
mainly  of  a greenish  yellow  matter,  streaked  with  blood, 
with  considerable  froth,  or  mucus,  and  so  offensive  to  the 
taste  or  smell  as  to  occasion  emesis. 

“I  was  completely  at  the  end  of  my  resources,  when 
I received  the  July  number  of  your  Journal.  I there 
found  two  or  three  cases  of  consumption,  by  Dr.  Bennett, 
treated  with  the  cod-liver  oil.  I at  once  determined  to 
try  it,  as  something  new,  but  with  little  hopes  of  finding 
any  good  come  of  it.  It  was  procured,  but  such  was  the 
irritability  of  the  stomach,  that  for  more  than  a week  its 
use  was  not  commenced,  during  which  neutral  mixture 
and  naphtha  were  again  used,  with  the  effect  of  quieting 


132 


CONSUMPTION— TREATMENT— COD-LIVER  OIL. 


it.  She  commenced  it  the  20th  of  August  ; a dessert- 
spoonful three  times  a day  was  taken  in  froth  of  porter. 
It  rested  easily  and  lightly ; in  a few  days  it  was  in- 
creased to  a tablespoonful  three  times  a day,  and  finding 
this  to  have  no  unpleasant  effect  on  the  stomach,  in  a few 
days  more  it  was  increased  to  four  tablespoonfuls  a day. 
This  quantity  wras  not  exceeded.  In  about  two  weeks, 
she  found  an  evident  improvement  in  her  appetite ; in 
two  weeks  more,  she  found  a diminution  of  her  fevers 
and  night  sweats,  nor  did  she  require  so  much  paregoric 
to  make  her  cough  supportable.  She  had  had  a constant 
blister  alternated  between  the  shoulders,  and  on  the  sca- 
pular portion  of  the  thorax,  which  she  had  neglected 
re-applying  for  some  days,  and  on  the  25th  of  September 
she  had  a severe  attack  of  pleuritic  pain,  for  which  I was 
summoned  in  haste  to  see  her.  The  blister  was  at  once 
applied,  and  removed  the  pain,  and  there  wms  no  more 
return  of  it. 

“ At  this  time,  when  she  w7as  on  the  use  of  the  fourth 
pint  of  oil,  the  loud,  cavernous  sound  in  the  axilla  was 
more  tracheal  than  formerly  ; pectoriloquy  was  less  dis- 
tinct, and  the  gurgling  rattle  wms  much  diminished ; 
bronchophony  still  well  marked  in  the  same  situations  as 
formerly. 

“ The  oil  was  persevered  with,  a tablespoonful  four 
times  a day.  At  the  end  of  October,  there  was  a great 
amelioration  of  all  the  symptoms  ; the  night  sweats  had, 
in  a great  measure,  disappeared ; the  chills  and  fevers 
were  gone  ; the  dyspeptic  symptoms  all  gone,  and  she 
had  a uniformly  good  appetite.  She  was  ordered  to  live 
Well,  on  good,  nourishing  food,  without  regard  to  what  it 
was,  if  no  unpleasant  effects  were  felt  in  the  stomach. 
Her  countenance  had  assumed  a natural,  sprightly  ex- 
pression ; her  strength  was  increasing ; her  dyspnoea 
(difficult  breathing)  decreasing,  and  everything  appear- 


CONSUMPTION— TREATMENT— COD-LIVER  OIL. 


133 


ed  favorable.  She  had  rarely  taken  paregoric  on  account 
of  the  cough,  but  the  blister  was  kept  sore.  In  another 
month,  there  was  not  a symptom  of  disease  remaining, 
except  some  cough  and  expectoration.  And  now,  25th 
of  December,  she  wTalks  about  the  streets,  straight  and 
erect,  not  as  strong  as  formerly,  but  can  walk  a mile  or 
more  without  great  fatigue.  She  weighs  some  pounds 
heavier  than  she  ever  did,  even  in  her  younger  days. 
Her  sallow  countenance  has  all  gone,  and,  although  she 
is  pale,  she  looks  sprightly,  talks,  laughs  with,  and  enjoys 
the  intercourse  of  her  friends  as  wrnll  as  before  she  wras 
sick.  Her  orthopnoea  has  disappeared  for  two  months, 
and  she  sleeps  easy  on  either  side,  though  rather  more  so 
on  the  left  than  on  the  right,  and  what  I regard  as  among 
the  most  favorable  signs  is,  her  catamenia  returned  in 
December. 

“ She  still  coughs  and  expectorates,  but  not  so  much 
in  a week  as  formerly  in  a day — and  the  expectoration 
continues  to  diminish.  The  sounds  in  the  chest  are  lit- 
tle more  than  a rather  loud  mucous  rattle,  with  little  or 
no  puffing,  dr  bronchophony.  In  the  axilla  is  a portion 
in  which  there  is  no  vesicular  murmur,  and  only  the 
mucous  rale,  but  not  so  strongly  marked. 

“ The  blister  has  not  been  applied  for  six  weeks  or 
more,  and  no  inconvenience  has  resulted  from  letting  it 
heal  up.  She  is  taking  a tablespoonful  of  the  oil  twice 
a day.  I am  fearful  yet  of  an  attack  of  influenza,  which 
is  prevailing,  to  some  extent,  in  her  case.  It  would,  in 
all  probability,  rekindle  the  disease.  But  certain  it  is 
she  is  nearly  well.  I doubt  very  much  whether  any 
other  article  could  have  produced  the  effects  that  have 
resulted  from  this.  Certainly,  it  is  not  known,  if  it  ex- 
ists.* All  known  means  had  been  tried,  and  most  faith- 

* Has  Dr.  Young  read  Dr.  McDowell’s  work  on  Consumption,  in  which 


134 


CONSUMPTION— TREATMENT— COD-LIVER  OIL. 


fully,  too,  before  she  commenced  the  use  of  this;  and  from 
no  one,  nor  from  all  successively  tried,  did  the  slightest 
benefit  accrue. 

“ I find  much  discrepancy  of  opinion  concerning  the 
kind  of  oil  most  medicinal.  The  kind  used  in  the  above 
case  was  the  fine,  clear,  white  oil.  It  cannot  be  procured 
for  less  than  one  dollar  a pint.  The  colored,  coarse  oil, 
at  about  half  this  price,  or  less,  I have  not  recommended, 
because  but  few  stomachs  could  bear  it  without  nauseat- 
ing, when  continued  for  the  length  of  time  necessary. 
The  effect  of  the  other,  instead  of  nauseating,  is  to  im- 
prove the  appetite,  and  the  digestive,  and  assimilating 
functions,  hence  it  ought  to  be  preferred  in  all  cases.  It 
is  to  be  apprehended  that  the  high  price  of  it  will  lead 
the  dishonest  to  making  an  inferior  imitation,  that  can  be 
sold  at  a cheaper  rate.  In  cases  of  this  kind,  as  in  many 
others,  the  cheap  article  is  dearest  in  the  end.  I am  try- 
ing it  in  three  other  hopeless  cases  of  consumption,  in 
which  all  other  means  have  failed.  They  are  all  im- 
proved, but  what  will  be  the  result  time  must  develop. 
They  have  not  taken  enough  yet  to  know  what  it  will 
do.  They  all  find  an  improvement  in  the  appetite,  and 
two  of  them  express  themselves  as  increasing  in  strength ; 
their  fevers  and  sweats  are  diminishing. 

“ Chester , Dec.  25,  1848.” 

In  an  essay  on  the  “ History  of  the  Fish-liver  Oil,” 
published  in  the  Gazette  Medicate  de  Paris,  the  follow- 
ing remarks  occur,  in  relation  to  the  composition  of  cod- 
liver  oil.  “ Chemical  researches  have  taught  us  that 
the  fish-liver  oil  ought  to  be  considered  as  a very  com- 
pound medicine.  Greasy  neutral  matter,  bilious  matter, 

he  informs  us  that  he  has  not  only  cured  one  case,  hut  scores  of  them,  prin- 
cipally by  the  preparations  of  iron,  good  diet,  &c.  &c.? 


CONSUMPTION— TREATMENT  OF. 


135 


iodine,  phosphorus,  each  of  them  well  known  as  possess- 
ing great  therapeutic  efficacy — also  a certain  number  of 
organic  elements,  such  as  butyric  acid,  gaduine,  and  some 
others,  the  medical  action  of  which  is  less  known- — finally, 
various  inorganic  salts,  as  the  phosphate  and  sulphate  of 
lime,  chloride  of  lime,  phosphate  and  sulphate  of  magne- 
sia, are  the  substances  of  which  it  is  composed.” 

In  looking  at  the  history  of  the  past,  to  the  experience 
of  the  world,  it  appears  that  we  now  have  two  remedies 
before  us,  which  promise  more  success  in  the  treatment 
of  consumption  than  all  others,  with  proper  attention 
and  other  hygienic  measures.  In  using  these  articles,  let 
us  not  go  blindly  along,  regarding  the  one  or  the  other, 
or  both,  as  specifics  ; but,  let  us  be  governed  by  rational 
principles  of  treatment,  and  perhaps  ere  long — instead 
of  bringing  these  articles  into  disrepute — the  world  may 
behold  thousands  of  living  trophies,  as  an  evidence  of 
the  success  of  the  healing  art  over  a disease  which  de- 
stroys such  vast  numbers  of  the  human  race. 

I would  suggest  the  addition  of  from  five  to  ten  grains 
of  the  citrate  of  iron,  or  from  five  to  twenty  grains  of  the 
subcarbonate  of  iron,  to  each  dose  of  the  cod-liver  oil. 
The  addition  of  capsicum  or  seneka,  or  some  other  appro- 
priate stimulant  may  be  necessary,  in  order  to  make  the 
fish-liver  oil  agreeable  to  the  stomach.  Our  own  coun- 
tryman, Dr.  McDowell,  who  is  the  author  of  one  of  the 
most  interesting  works  extant,  on  the  treatment  of  con- 
sumption, speaks  favorably  of  the  preparations  of  iron; 
the  use  of  stimulants,  as  brandy,  wine,  &c.,  puccoon 
root  ( sanguinaria  Canadensis ),  common  salt,  good  living, 
&c.  &c. 

When  the  tubercles  produce  inflammation  in  the  lung, 
as  evinced  by  increased  stricture  and  pain  in  the  chest, 
more  incessant  coughing,  and  more  feverishness ; the  re- 
medies recommended  above,  with  the  exception  of  the 


136 


CONSUMPTION— TREATMENT  OF. 


cod-liver  oil,  should  be  suspended  for  a few  days,  till  the 
inflammation  is  in  a great  measure  subdued  by  moderate 
purging,  cupping,  leeching,  or  a blister  over  the  seat  of 
pain,  or  between  the  shoulders;  and  in  rare  incipient 
cases,  where  the  febrile  excitement  is  considerable,  a 
small  bleeding  from  the  arm  might  be  of  service.  Blue 
mass  or  calomel,  with  extract  of  white  walnut  or  rhubarb, 
should  be  given  (repeated,  if  necessary,  once  or  twice, 
with  intervals  of  twelve  or  twenty-four  hours),  so  as  to 
act  somewhat  freely  on  the  bowels.  In  the  mean  time 
small  doses  of  tartar  emetic  or  ipecac.,  with  tincture  of 
digitalis,  or  tincture  of  lobelia,  should  be  given  from  three 
to  five  or  six  times  a day.  As  the  inflammation  increases 
the  deposition  of  tubercular  matter,  it  is  of  importance 
that  it  should  be  subdued.  For  the  exhibition  of  the  re- 
medies last  mentioned,  the  following  recipe  may  answer 
the  purpose: — 

R . W ater  one  and  three-quarter  ounces  ; 

Tartar  emetic  four  grains  ; or, 

Ipecac.  sixteen  grains ; 

Tinct.  digital,  three  teaspoonfuls. 

Mix.  Dose,  one  teaspoonful,  from  three  to  five,  or  six 
times  a day,  according  to  the  intensity  and  persistence  of 
the  inflammation.  As  the  inflammation  subsides,  and 
before  it  is  thought  proper  to  recur  again  to  the  use  of  the 
iron  and  stimulants,  the  following  may  be  given  : — 

R.  Water  two  and  a half  ounces; 

Sulph.  zinc.  twenty-four  grains ; 

Tinct.  digital,  three  and  a half  drachms  ; 

Tinct.  lobelia  three  ounces. 

First  dissolve  the  zinc  in  the  water,  then  add  the  other 
ingredients,  and  shake  the  bottle.  Dose,  a dessertspoon- 
ful (or  less,  if  it  should  nauseate  too  much),  from  three 
to  four  or  five  times  a day.  Sulphate  of  quinine  may  be 
added  at  this  time  to  the  fish-liver  oil,  in  doses  of  four  or 


CONSUMPTION— TREATMENT— DIET. 


137 


five  grains.  Duringthe  inflammatory  condition  of  the  lung, 
as  well  as  at  all  others,  the  cough  and  pain  should  be  con- 
trolled or  modified  by  opiates.  Sulphate  of  morphine 
may  be  given,  in  doses  of  from  one-quarter  to  one-half  a 
grain  or  more,  if  necessary ; or,  if  there  is  not  much  feb- 
rile excitement,  laudanum  may  be  given  in  doses  of  from 
thirty  to  sixty  drops ; so  as  to  control  or  modify  the  cough 
and  pain,  and  assist  in  reducing  the  inflammation.  At 
other  times,  paregoric  will  answer  to  modify  the  cough  ; 
or,  if  there  is  much  attendant  chronic  bronchitis,  chronic 
tracheitis,  or  chronic  laryngitis,  with  free  expectoration, 
some  of  the  cough  mixtures  we  shall  notice,  when  we 
come  to  speak  of  chronic  bronchitis,  may  be  used  with 
advantage. 

With  regard  to  the  incessant  use  of  blisters,  issues, 
setons,  and  moxas  in  consumption,  I believe  they  are 
usually  detrimental ; principally  on  account  of  the  irrita- 
tion and  debility  they  induce,  and  the  undue  reliance 
placed  on  them  to  the  neglect  of  more  appropriate  reme- 
dies, to  say  nothing  of  their  offensiveness,  and  the  atten- 
tion they  require  from  the  patient.  They  should  be  re- 
garded as  relics  of  barbarism,  unbecoming  an  enlightened 
age.  The  occasional  application  of  a blister,  under  the 
circumstances  mentioned  above,  when  their  use  is  indi- 
cated by  the  supervention  of  inflammation  of  the  lung  or 
pleura,  in  conjunction  with  the  other  appropriate  means 
for  the  reduction  of  the  inflammation,  may  be  of  service, 
and  should  not  be  neglected. 

Sponging  the  body  with  cold  water,  once  or  twice  a 
day,  when  the  stomach  is  empty,  especially  in  warm 
weather,  may  be  of  benefit. 

Diet. — The  diet  of  the  consumptive  is  a matter  of 
much  importance,  and  should  consist  of  a liberal  range 
or  variety  of  nourishing  articles  of  diet,  which  are 

10 


138 


CONSUMPTION— TREATMENT— DIET. 


easily  digested  and  acceptable  to  the  stomach;  but  care 
should  be  taken  that  the  stomach  be  not  oppressed  with 
more  food  at  a time  than  can  be  digested.  Animal  diet, 
as  the  different  kinds  of  flesh;  wheat  or  common  corn 
(maize)  bread  ; Irish  potatoes ; and  other  articles  which 
abound  in  starch  and  saccharine  matter ; molasses ; sugar; 
rice;  milk;  minced  pies,  with  some  brandy  in  them,  so 
as  to  make  them  better  agree  with  a weak  stomach, 
and  such  like  articles  should  be  eaten;  taking  care 
that  they  are  properly  prepared.  Common  salt  ( chloride 
of  sodium)  should  be  used  freely  as  a condiment;  in- 
deed, it  has  been  highly  spoken  of  by  some  practition- 
ers, particularly  by  Dr.  McDowell,  as  a remedy  in  con- 
sumption. Other  condiments,  as  pepper,  mustard,  &c., 
may  be  used,  at  the  option  of  the  patient.  During  the 
spells  of  inflammation  above  noticed,  the  diet  should  be 
rather  light  for  a few  days ; consisting  of  tapioca,  sago, 
rice,  milk,  molasses,  arrowroot,  and  the  like. 

Free  and  regular  exercise  in  the  open  air,  when  it  can 
be  comfortably  borne,  short  of  inducing  fatigue;  full  and 
free  respiration,  frequently  fully  expanding  the  chest  by 
foil  inspirations;  and  holding  the  body  erect,  so  as  not  to 
bend  over  and  oppress  the  chest ; should  receive  proper 
attention.  An  equable  and  healthful  atmosphere  is  de- 
sirable, so  that  all  the  advantages  of  out-door  exercise 
may  be  obtained.  To  those  opulent  persons  who  wish 
to  seek  a winter  retreat  awav  from  home,  I would  say, 
that  Dr.  M.  Wilson,  of  the  city  of  Jackson,  Mississippi, 
from  personal  experience,  speaks  very  favorably  of  the 
island  of  Curacoa,  near  the  coast  of  South  America,  as 
being  remarkable  for  its  equable  temperature,  and  health- 
ful and  saline  atmosphere.  Pensacola,  Florida,  is  also 
said  to  be  a favorable  winter  residence  for  the  consump- 
tive valetudinarian.  Sea  voyages  are  said  to  have  a fa- 
vorable influence  in  many  cases. 


SCROFULA— RICKETS. 


139 


CHAPTER  V l 
SCROFULA— RICKETS. 

Scrofula. — The  cod-liver  oil  is  also  very  favorably 
spoken  of,  especially  by  German  physicians,  and  some 
others,  in  the  treatment  of  the  different  forms  of  scrofula; 
whether  the  lymphatic  glands  about  the  neck,  arm-pits, 
groins,  and  elsewhere  ; or,  in  fact,  in  all  forms  of  scrofu- 
lous disease ; whether  it  affect  the  lymphatic  glands,  skin, 
ends  of  the  long  bones,  etc.  It  is  used  both  internally 
and  externally,  by  rubbing  it  over  the  affected  parts.  In 
these  cases,  I think  it  would  be  advisable  to  combine 
iodide  of  iron  with  the  fish-liver  oil — say  three  or  four 
grains  of  the  iodide  to  each  dose  of  the  fish -liver  oil,  three 
times  a day.  It  would  probably  be  well,  after  using  the 
iodide  of  iron  for  a week  or  two,  to  alternate  for  the  same 
length  of  time  with  the  subcarbonate  or  citrate  of  iron, 
still  taking  the  cod-liver  oil.  Diet,  as  in  consumption. 

Rickets. — The  German  and  Dutch  physicians,  with 
great  unanimity,  affirm  that  the  fish-liver  oil  is,  without 
exception,  the  best  remedy  for  rachitis , in  all  its  stages, 
and  under  whatever  form  it  presents  itself.  “ According 
to  Dr.  Schmidt,  who  has  most  insisted  on  the  advantages 
of  this  medicine,  in  twenty-one  rachitic  patients  which 
he  had  treated,  at  the  time  when  he  made  known  its  re- 
sults, thirteen  were  cured,  and  four  were  in  the  process  of 
being  cured  ; as  to  the  others,  judging  from  the  progress 
which  they  had  made  for  the  little  time  they  were  under 
treatment,  a very  favorable  prognosis  might  be  drawn.” 
In  relation  to  this  subject,  Professor  Trosseau,  in  France, 


140 


CHRONIC  RHEUMATISM— TREATMENT  OF. 


thus  expresses  himself:  “We  have  often  obtained  cures, 
the  rapidity  of  which  surpassed  our  expectation.  Some- 
times, after  four  days  of  treatment,  the  sharp  pains  which 
the  children  felt  in  all  their  limbs  ceased  ; and  the  bones 
which  could  be  bent,  acquired,  at  the  end  of  five  days, 
a considerable  solidity.”  The  fish-liver  oil  may  be  given 
to  children  in  doses  of  a teaspoonful,  three  times  a day. 
Perhaps  it  would  be  well  to  add  one  or  two  grains  of  the 
subcarbonate  or  citrate  of  iron  to  each  dose,  and,  if  neces- 
sary, to  make  it  agreeable  to  weak  stomachs,  the  addition 
of  a couple  of  grains  of  capsicum,  or -other  stimulants. 
Good  diet,  and  moderate  exercise,  if  it  can  be  comfortably 
borne,  together  with  other  hygienic  measures,  should  re- 
ceive proper  attention. 

Chronic  Rheumatism. — I would  not  mention  the  sub- 
ject of  chronic  rheumatism  in  this  connection,  if  it  was 
not  from  the  fact  that  we  have  already  incidentally  men- 
tioned it,  in  speaking  of  Dr.  Bennett’s  views  in  relation 
to  the  therapeutic  action  of  cod-liver  oil;  and  that  a large 
number  of  German  physicians,  who  have  all  published 
their  own  observations,  consider  it  to  possess  such  an 
efficacy  in  this  disease,  that  it  surpasses,  in  their  opinions, 
all  other  remedies,  without  excepting  the  most  lauded 
anti-rheumatics. 

“ This  opinion  of  different  physicians,  wdio  have  all 
experimented  by  themselves,  cannot  be  taxed  with  exag- 
geration, if  it  is  considered  that  amongst  these  cases  there 
are  found  numerous  instances  of  rheumatic  patients  being 
cured,  who,  after  many  years  of  suffering,  and  usage  of 
all  sorts  of  remedies,  having  lost  their  strength  and  de- 
spairing of  cure,  were  completely  cured  by  the  aid  of  the 
fish-liver  oil. 

“ Rheumatic  Sciatica. — The  fish-liver  oil  did  not  prove 
less  efficacious  in  this  form  of  chronic  rheumatism,  which 


CHRONIC  RHEUMATISM— TREATMENT  OF. 


141 


is  generally  distinguished  by  its  obstinacy ; this  is  veri- 
fied by  the  observations  of  MM.  Knood  von  Helmend- 
streit,  Rust,  Amelung,  Munzenthaler,  Lettinger,  and 
Spitter.”* 

Dr.  Mackintosh’s  experience  is  not  favorable  to  the  use 
of  the  fish-liver  oil  in  chronic  rheumatism.  In  addition 
to  the  internal  use  of  the  oil,  it  may  be  well  to  rub  some 
of  it  up  with  some  soothing  ointment,  as  the  ointment  of 
Jamestown  weed,  (“jimpson  weed’’),  which  should  be 
rubbed  on  the  afflicted  joints  twice  a day.  Iodine-]  impson 
weed  ointment  may  be  applied  with  profit  in  these  cases. 

The  cod-liver  oil  may  be  taken  alone,  in  coffee,  lemon 
juice,  or  otherwise,  so  as  to  obscure  its  taste.  Admitting 
it  to  possess  all  the  virtues  claimed  for  it  by  its  friends, 
it  is  to  be  presumed  that,  in  a great  many  cases,  patients 
cannot  be  induced  to  persevere  in  its  use  sufficiently  long 
to  secure  all  the  benefits  which  it  is  capable  of  affording. 

My  esteemed  friend,  Erasmus  S.  Broyles,  M.  D.,  of 
Aberdeen,  Mississippi,  informed  me,  last  year,  when  I 
was  on  a visit  to  that  place,  that  an  indigenous  herb, 
which  grew  in  the  neighborhood,  was  attracting  some 
notice  as  a remedy  for  chronic  rheumatism.  He  knew  no 
name  for  it. 

Spirits  of  turpentine  is  a common  remedy  in  chronic 
rheumatism,  especially  in  sciatica  and  lumbago.  It  may 
be  taken  in  doses  of  from  ten  to  twenty  drops  two  or 
three  times  a day ; and  also  rubbed  over  the  affected 
parts.  The  “ steam  bath ” may  be  regarded  as  a valuable 
adjuvant,  as  well  as  acupuncturation  and  electricity; 
the  latter,  in  cases  that  appear  to  be  more  strictly  of  a 
nervous  character,  and  in  which  there  is  no  organic  alte- 
ration or  enlargement.  I would  recommend  the  more 
general  use  of  puccoon  root,  iron,  quinine,  and  zinc. 

* Gazette  Medicate,  and  Dublin  Med.  Press.  See  also  Am.  Journ.  Med. 
Sci.,  Oct.  1848. 


142 


CHRONIC  RHEUMATISM— TREATMENT  OF. 


Many  cases  of  chronic  rheumatism  seem,  in  a great 
measure,  to  be  brought  on  by  the  constant  use  of  spiritu- 
ous liquors,  in  which  cases  the  features  usually  present 
a florid  appearance,  and  it  is,  perhaps,  to  these  that  col- 
chicum,  hydriodate  of  potash,  the  warm  or  vapor  bath, 
and  wearing  flannel  next  the  skin,  are  found  to  be  useful. 
But  I am  of  opinion  that  a large  majority  of  the  cases  in 
the  South  are  of  an  ancemic  nature — the  system  being  re- 
laxed, debilitated,  the  flesh  soft,  and  the  appearance  of  the 
patient  more  or  less  pallid — and  demand  a very  different 
mode  of  treatment.  These  cases  appear  to  be  more 
strictly  of  a nervous  character;  indeed,  I consider  them 
a species  of  neuralgia,  with  less  or  more  attendant  anae- 
mia, like  many  other  nervous  affections.  Perhaps  in 
all,  or  nearly  all,  these  cases,  there  will  be  some  degree 
of  spinal  irritation,  or  pain  in  the  back,  which  may  usually 
be  ascertained  by  firm  pressure,  made  with  the  fingers, 
along  the  spine,  from  the  back  of  the  neck  down  to  the 
lumbar  region  ; the  place  where  the  spinal  affection  exists 
being  indicated  by  tenderness,  or  even  pain,  when  firm 
pressure  is  made  on  it. 

For  the  cure  of  this  form  of  rheumatism,  take  a dose 
composed  of  subcarbonate  of  iron,  from  10  to  30  grains; 
2 or  3 grains  of  quinine ; and  from  40  to  60  drops  of 
tincture  of  puccoon  root,  twice  or  three  times  a day,  and 
continue  the  treatment  till  a cure  is  effected.  In  those 
cases  of  a somewhat  more  florid  appearance,  the  tincture 
of  puccoon  root,  with  four  or  five  grains  of  Prussian  blue, 
would,  perhaps,  be  better  adapted  ; or  a dose  of  sulphate 
of  zinc  (from  half  a grain  to  a grain)  may  be  taken  with 
the  puccoon.  Iodine  ointment,  rubbed  over  the  tender 
portion  of  the  spine  every  night,  or  eveiy  other  night,  or 
put  on  a sticking  plaster  and  worn,  may  be  of  service. 
Sponging  the  body  with  cool  water,  or  the  shower  bath, 
every  morning,  is  invigorating,  and  well  calculated  to  do 


CHRONTC  BRONCHITIS. 


143 


much  good.  Costiveness  should  be  prevented  by  extract 
of  dandelion,  rhubarb,  extract  of  white  walnut,  or  the 
like. 


CHAPTER  VI. 

TABES  MESENTERICA 

Being  a scrofulous  disease,  which  affects  principally 
the  glands  of  the  mesentery,  requires  the  same  general 
principles  of  treatment  as  the  other  forms  of  scrofulo- 
sis.  As  a remedy,  the  cod-liver  oil  has  recently  been 
favorably  spoken  of.  It  may  be  taken  in  teaspoonful 
doses  three  times  a day.  If  it  is  used  at  all,  I would 
recommend  the  addition  of  the  subcarbonate,  citrate,  or 
sulphate  of  iron,  in  doses  of  two  or  three  grains  of  the 
subcarbonate  or  citrate,  and  half  a grain  to  a grain  of  the 
sulphate.  I would  also  recommend  the  free  use  of  iodine 
ointment,  over  the  region  of  the  abdomen,  every  night 
or  two.  To  check  the  diarrhoea  that  sometimes  attends 
this  disease,  paregoric,  catechu,  krameria,  tannin,  or  a 
combination  of  any  of  these  with  the  paregoric,  or  lauda- 
num, may  be  given.  If  costiveness  attends,  aperients 
should  be  given. 


CHAPTER  VII. 

CHRONIC  BRONCHITIS. 

In  the  malarious  regions  of  the  South,  in  that  anccmic 
or  cachectic  condition  which  is  induced  by  protracted  ague 
and  fever,  chronic  bronchitis  is  not  unfrequently  a very 


144 


CHRONIC  BRONCHITIS— TREATMENT  OF. 


troublesome  and  distressing  affection;  and,  connected 
with  the  pale  and  sickly  aspect,  is  often  regarded  as  the 
incipient  stage  of  consumption ; which  latter,  indeed, 
from  neglect  or  improper  treatment,  is  perhaps,  not  un- 
frequently,  made  veritable.  This  form  of  bronchitis  is 
sometimes  primary,  like  serous  pohjcemia , not  being 
always  preceded  by  ague  and  fever.  It  lasts  for  months, 
and  even  years,  and,  if  not  cured,  may  lead  to  consump- 
tion and  death.  The  trachea  ( chronic  tracheitis)  and  lar- 
ynx ( chronic  laryngitis ),  are  frequently  involved,  usually 
making  the  expectoration  much  more  copious.  There  is 
in  every  case  more  or  less  troublesome  cough,  with  ex- 
pectoration more  or  less  free ; the  matter  thrown  up 
varying  in  appearance,  frequently  of  a yellowish  white, 
or  a mixture  of  white  and  yellow,  in  some  cases  occa- 
sionally streaked  with  a little  blood.  There  is  usually 
more  or  less  hoarseness,  the  voice  being  somewhat  rough 
and  flat. 

Treatment. — Having  recently  succeeded  in  promptly 
curing  several  cases,  in  which  the  patients,  having 
sought  relief  in  vain  from  several  physicians,  had  almost 
entirely  despaired  of  a cure,  some  of  them  fearing  they 
were  treading  a similar  course  to  some  of  their  relatives 
or  friends  who  appeared  to  be  similarly  affected,  and 
some  of  whom  suffered  much  for  years,  and  others,  who 
finally  succumbed  to  consumption,  I will  briefly  make 
known  the  treatment  I adopt  in  such  cases.  I use  several 
mixtures,  more  or  less  modified,  so  as  to  adapt  them  to 
each  case  respectively.  The  following  may  be  consi- 
dered as  examples  of  them  : — 

R,  Balsam  copaiva  one  ounce  ; 

Paregoric  one  and  a half  ounces  ; " 

Tincture  of  puccoon  root  one  and  a half  ounces. 

Mix,  and  shake  w’ell  just  before  using.  Dose,  from 


CHRONIC  BRONCHITIS— TREATMENT  OF. 


145 


forty  to  sixty  drops,  or  even  more,  three  times  a day, 
mixed  with  a little  sugar. 

E.  Water  one  ounce; 

Sulph.  zinc  two  scruples  ; 

Paregoric  one  ounce  and  sis  drachms  ; 

Tincture  of  puecoon  one  ounce  and  sis  drachms  ; 

Balsam  copaiva  one  ounce. 

Dissolve  the  white  vitriol  in  the  water;  then  add  the 
other  ingredients,  and  shake  well  just  before  using.  Dose, 
a teaspoonful,  thrice  daily,  mixed  with  a little  sugar. 

E.  Balsam  copaiva  one  ounce  and  sis  drachms  ; 

Paregoric  one  ounce  and  two  drachms. 

Mix,  and  shake  well  just  before  using.  Dose,  thirty- 
five  to  sixty  drops,  three  times  a day,  mixed  with  sugar. 

As  the  cough  subsides,  the  dose  of  any  of  the  above 
should  gradually  be  diminished.  Should  a subacute  in- 
flammatory condition  arise,  which,  however,  is  rarely  the 
case,  the  above  mixtures  should  be  temporarily  sus- 
pended, the  bowels  moved  somewhat  freely,  as  with  the 
extract  of  the  white  walnut,  &c.,  and  the  following  sub- 
stituted in  place  of  either  of  the  cough  mixtures  above. 

E.  Water  four  drachms ; 

Sulph.  zinc  twenty-four  grains  ; 

Tinct.  digitalis  six  drachms  ; 

Tinct.  lobelia  two  ounces. 

Dissolve  the  white  vitriol  in  the  water;  then  add  the 
other  ingredients,  and  shake  it.  Dose,  a teaspoonful, 
three  or  four  times  a day.  If  the  cough  is  troublesome, 
a little  sulphate  of  morphine  may  be  added  to  the  above, 
say  from  three  to  five  grains,  dissolved  in  the  water  with 
the  zinc,  before  the  other  articles  are  added ; or,  it  may 
be  added  to  the  entire  mixture  subsequently,  if  desired, 
after  the  mixture  has  been  made. 

During  the  treatment,  costiveness  should  be  avoided 
by  the  use  of  pills  cf  extract  of  dandelion  and  rhubarb, 


146 


CHRONIC  BRONCHITIS— TREATMENT  OF. 


extract  of  white  walnut,  or  the  like.  Conjointly  with 
the  other  treatment,  I am  in  the  habit  of  advising  the 
cold  dash  to  the  neck,  and  between  the  shoulders,  once  or 
twice  a day;  especially  in  warm  and  mild  w'eather.  At 
those  times  I think  it  of  too  much  importance  to  be  ne- 
glected ; indeed,  the  patient  may  be  profited  by  a shower 
bath  once  a day,  taken  early  in  the  morning,  or  on  an 
empty  stomach  at  any  time.  Perhaps  also  the  best  time 
for  taking  the  cold  dash  is  early  in  the  morning. 

In  some  obstinate  cases,  in  which  the  fauces  become 
involved,  it  may  be  necessary  to  resort  to  local  applica- 
tions, conjointly  with  the  above  treatment;  of  which, 
lunar  caustic,  either  in  the  solid  state  or  strong  solution, 
is  probably  the  best.  If  the  solid  caustic  be  used,  the 
inflamed  or  ulcerated  surfaces  should  be  penciled  over 
with  it,  if  they  can  be  reached.  If  the  solution  be  used, 
it  may  be  applied  by  means  of  saturating  a piece  of  sponge 
fastened  to  the  end  of  a whalebone,  or  by  lint,  or  a soft 
rag,  fastened  to  the  end  of  the  finger  of  a glove,  which 
should  be  applied  to  the  inflamed  or  ulcerated  surfaces. 
This  should  be  repeated  as  often  as  occasion  requires — 
every  day  or  two,  or  less  frequently,  in  mild  cases. 

The  affection  called  clergyman' s sore-tliroat , is  of  the 
above-described  nature,  requiring  rest  from  much  speak- 
ing, and  the  use  of  the  same  means. 

Of  course,  if  the  concomitant  cachectic  or  anaemic 
condition  of  the  system  should  be  very  manifest,  it 
should  at  the  same  time  meet  with  proper  attention 
by  the  exhibition  of  some  of  the  preparations  of  iron, 
heretofore  noticed  as  proper  for  these  conditions  of  the 
system.  In  these  cases,  the  iron  and  cough  mixture 
may  be  taken  together.  Good  diet,  free  exercise  in  the 
open  air,  and  other  hygienic  measures  which  have  a 
tendency  to  invigorate  the  system,  should  receive  proper 
attention. 


HAEMOPTYSIS,  OR  SPITTING  OF  BLOOD. 


147 


CHAPTER  VIII. 

haemoptysis,  qk  spitting  op  blood. 

In  some  cases  of  anczmia , whether  primary  or  second- 
ary, the  sequel  to  malarious,  or  other  diseases  which  pro- 
duce a similar  influence,  in  consequence  of  the  blood- 
globules  being  diminished ; the  blood  thereby  becoming 
too  thin,  with  concomitant  relaxation  of  the  system,  and 
debility;  complicated  in  some  cases  with  organic  disease, 
as  of  the  liver,  spleen,  heart,  or  lungs,  &c., — but  not  un- 
frequently,  when  it  does  occur,  without  any  of  these  com- 
plications,— bleeding  takes  place  from  some  of  the  mu- 
cous surfaces,  they  being  relaxed  and  softened,  permit- 
ting the  thinned  blood  to  pass  out  by  diapedesis  or  transu- 
dation. Transudation  may  in  some  cases,  also,  take  place 
in  other  parts  of  the  system. 

An  interesting  case  of  haemoptysis  recently  came 
under  the  writer’s  professional  care,  which  has  been  of 
some  eight  years’  standing,  with  occasional  temporary 
improvement,  and  longer  intervals,  and  then  again 
becoming  worse.  This  case  occurred  in  the  person  of 
Mr.  C.  H.  Bean,  formerly  of  Jonesborough,  East  Ten- 
nessee, heretofore  a printer  by  trade,  but  now  a teacher 
of  monochromatic  and  polychromatic  landscape  painting. 
Strange  to  say,  soon  after  the  development  of  the  disease 
(which  he  attributes  to  cold,  and  close  application  in  the 
printing  office),  according  to  his  statement,  his  medical 
advisers  recommended  very  abstemious  diet,  till,  for  nearly 
two  years,  he  almost  starved  himself  to  death,  continually 
getting  worse.  He  resolved  to  travel,  and  use  liberal 
diet,  during  which  time  he  began  to  improve;  but  now 


148 


SPITTING  OF  BLOOD. 


and  then  would  again  get  worse.  From  inquiring  of 
him  the  plans  of  treatment  recommended  by  different 
physicians,  it  appears  that  none  correctly  appreciated  the 
nature  and  proper  treatment  of  his  malady,  but  Drs.  Paul 
F.  and  Jos.  Eve,  of  Augusta,  Georgia,  whose  direc- 
tions he  had  in  part  only  complied  with.  He  used  con- 
secutively, and  strictly  according  to  the  directions,  twelve 
bottles  of  “ Wistar’s  balsam  of  wild  cherry,''  under  which 
patent  nostrum  he  continually  grew  worse  and  worse, 
till  he  was  very  much  reduced.  He  also  used  a large 
amount  of  “ Brandreth' s pills ,”  which,  instead  of  proving 
beneficial,  were  injurious.  He  also  tried  the  “ honey  of 
bonesetf  another  patent  nostrum,  which  nearly  killed 
him.  Mr.  Bean  talks  of  writing  out  his  woful  experi- 
ence with  these  articles,  in  order  that  the  public  may  be 
benefited  thereby ; that  thousands  may  save  their  consti- 
tutions from  being  wrecked  by  these  and  other  nostrum 
speculations,  at  the  expense  of  human  happiness  and 
human  life.  Would  that  he  had  sufficient  character  and 
influence  to  effect  much  good.  I have  put  Mr.  Bean 
under  the  use  of  the  subcarbonate  of  iron,  recommending 
him  to  occasionally  (say  every  week  or  two),  alter- 
nate with  the  syrup  of  iodide  of  iron,  in  doses  of  from 
twenty  to  forty  drops  three  times  a day,  in  sweetened 
water.  I have  advised  him  to  now  and  then  use  other 
preparations  of  iron,  the  moderate  use  of  wine  or  brandy, 
good  diet,  and  free  out-door  exercise.  The  spells  of 
bleeding  are  preceded  by  premonitory  symptoms  of 
tickling  about  the  throat,  and  coughing,  with  more  or  less 
disturbance  of  the  nervous  system,  as  chilliness,  unplea- 
sant sensations  in  the  region  of  the  stomach  or  spleen, 
&c.  On  the  appearance  of  these  premonitory  symptoms, 
I have  advised  him  to  take  a dose  of  quinine  (five  or  six 
grains)  and  laudanum  (thirty  or  forty  drops),  in  order  to  try 
to  avert  a spell  of  bleeding,  which  comes  on,  with  shorter 


SPITTING  OF  BLOOD. 


149 


or  longer  intervals  of  a month  or  more.  In  cases  of  hemo- 
ptysis, the  blood  thrown  up  is  of  a red,  frothy  appearance 
(till  towards,  or  during  the  subsidence  of  the  bleeding,  it 
is  inclined  to  a darker  hue),  and  sometimes  so  copious  as 
to  excite  considerable  alarm.  Usually,  it  is  easily  and 
promptly  arrested  by  a solution  of  sugar  of  lead  and 
laudanum ; or  a solution  of  alum  and  laudanum,  in  free 
doses,  repeated  as  circumstances  require.  Drs.  Copland 
and  Willshire  speak  highly  of  the  oil  of  turpentine. 
Common  salt  is  recommended  by  some  authors.  Solu- 
tions of  sugar  of  lead,  alum,  &c.,  may  also  frequently  be 
used  as  a gargle.  Mental  and  corporeal  quietude  should 
be  observed,  and  the  apartment  of  the  patient  venti- 
lated and  rendered  agreeable.  In  the  case  noticed  above, 
there  is  chronic  laryngitis,  with  a rather  copious  muco- 
purulent expectoration,  and  which  might  no  doubt  be 
greatly  benefitted  by  the  local  application  of  lunar  caus- 
tic. This  case  will  certainly  require  a very  protracted 
use  of  the  preparations  of  iron,  and  other  hygienic  mea- 
sures, to  effectually  change  the  diathesis  of  the  system, 
to  improve  the  blood,  and  to  effectually  put  a stop  to  this 
hsemorrhagic  proclivity.  And  here  I wish  it  particu- 
larly borne  in  mind,  in  all  such  cases,  that  the  prepara- 
tions of  iron  should  be  persisted  in  till  the  health  is 
fully  restored,  and  a pale,  sallow  appearance  has  given 
place  to  one  of  redness,  freshness,  and  vigor.  Any  con- 
comitant visceral  disease  should  receive  appropriate  at- 
tention. 

In  conclusion,  I may  remark  that  the  hsemorrhagic  dia- 
thesis in  those  of  an  opposite  condition , that  in  which 
there  is  hypercemia , or  too  much  blood,  with  a full,  florid 
appearance,  requires  a different  treatment  from  the  one 
recommended  above,  occurring  in  anemic  subjects.  This 
requires  venesection,  purging,  sugar  of  lead,  and  an  ab- 
stemious diet. 


150 


DROPSY— TREATMENT  OF. 


Hydro-poly^emta,  or  Serous  Poly^emia,  heretofore 
mentioned  and  described,  should  be  treated  with  the  pre- 
parations of  iron,  generous  and  varied  diet,  as  recom- 
mended under  the  head  of  “ Cachexia , Treatment  of 


CHAPTER  IX. 

DROPSY— TREATMENT  OF. 

For  the  several  forms  of  dropsy  previously  noticed, 
the  general  principles  of  treatment  are  the  same.  The 
muriated  tincture  of  iron,  in  doses  of  from  twenty  to  sixty 
drops  for  adults,  and  from  five  to  fifteen  drops  for  chil- 
dren, dilated  with  water,  taken  three  or  four  times  aday, 
in  conjunction  with  the  use  of  blue  mass,  is,  perhaps,  one 
of  the  best  plans  of  treatment.  Other  diuretics  may  be 
alternated  with  the  muriated  tincture  of  iron,  after  usino- 
it  four  or  five  days.  For  this  purpose,  the  vinegar  or 
syrup  of  squills,  sweet  spirits  of  nitre,  balsam  copaiva, 
&c.,  may  be  used.  But  in  this  pale  and  bloated  condi- 
tion of  the  system,  it  seems  to  demand  the  tincture  of 
iron  more  particularly.  Blue  mass  should  be  given  everj* 
night  or  twro,  so  as  to  purge  mildly;  but,  after  giving  it 
for  six  or  eight  days  in  this  manner,  it  should  be  sus- 
pended for  awhile;  and  if  necessary,  in  three  or  four 
days  it  may  be  resumed  again.  Its  influence,  however, 
should  be  watched  with  some  care;  for  if  it  is  pushed 
to  salivation,  it  might  prove  injurious  to  the  system  in 
this  debilitated  condition,  and  injuriously  affect  the  con- 
stitution. In  the  fall  of  1848,  a lad  about  thirteen  years 
old,  who  had  been  suffering  with  asuie  and  fever  for  some 
time,  came  under  the  professional  care  of  the  writer.  He 
presented  a general  dropsical  appearance,  with  hydrocele, 


DROPSY— TREATMENT  OF. 


151 


which  latter  I was  principally  called  upon  to  treat,  as  his 
brother  had  died  of  the  same  affection  the  year  previous, 
and  his  parents  began  to  fear  that  this  one  would  soon 
meet  with  the  same  fate.  I treated  him  with  the  muri- 
ated  tincture  of  iron  and  blue  mass ; and  pressure  with 
a soft  pad,  and  a T bandage.  The  dropsical  effusion  was 
soon  absorbed,  after  which  I gave  him  a mixture  of  sub- 
carbonate  of  iron,  capsicum,  and  quinine;  he  still,  now 
and  then,  having  a chill.  He  improved  rapidly.  A gen- 
tleman about  forty  years  of  age  came  under  the  au- 
thor’s professional  care,  who  was  suffering  with  chills 
and  fever;  spleen  very  much  enlarged;  indeed,  enor- 
mously so;  belly  much  swelled,  from  the  enlargement  of 
the  spleen,  and  ascites;  legs  very  much  swelled,  &c. 
&c.  I put  him  under  a treatment  similar  to  the  above, 
that  is,  under  the  use  of  the  muriated  tincture  of  iron  and 
blue  mass,  and  he  rapidly  improved.  I advised  him 
after  the  dropsical  effusions  were  removed,  to  use  some 
of  the  preparations  of  iron  pretty  freely.  I merely  call 
a passing  attention  to  these  two  cases,  to  show  the  suc- 
cess of  the  plan  of  treatment,  and  to  point  out  the  proper 
treatment  briefly,  adapted  to  cases  of  these  kinds.  Au- 
thors recommend  hydragogue  cathartics  in  dropsy,  such 
as  jalap  and  cream  of  tartar,  elaterium,  &c.  &c. ; but  as 
this  practice  seems  more  directed  to  the  removal  of  the 
effects  of  certain  morbid  conditions,  without  removing 
the  cause,  if  principally  relied  upon,  it  often  fails  of  suc- 
cess; and  in  many  cases,  no  doubt,  proves  injurious;  or 
at  least  suffers  the  morbid  condition  which  o-ives  rise  to 
the  dropsy,  to  continue.  The  concomitant  visceral  affec- 
tions, as  well  as  the  general  condition  of  the  system, 
should  meet  with  appropriate  attention.  The  diet  should 
be  somewhat  restricted,  though  sufficiently  nutritious,  till 
the  dropsical  effusions  have  been  removed;  then  it  should 
be  improved  and  of  good  quality. 


152 


ENLARGEMENT  OF  THE  SPLEEN,  ETC. 


CHAPTER  X. 

ENLARGEMENT  OF  THE  SPLEEN  AND  SPLENIC 
CACHEXIA. 

Enlargement  of  the  Spleen  is  well  known  to  be  of 
common  occurrence  in  the  malarious  regions  of  the  South; 
occurring  especially  in  ague  and  fever,  or  congestive  fever; 
frequently  remaining  enlarged , and  not  unfrequently 
becoming  hypertrophied  or  indurated , after  these  diseases 
have  been  cured.  When  the  enlargement  is  recent,  or 
has  only  been  of  short  duration,  it  depends  on  engorge- 
ment, hyper cemia , fulness  of  blood:  when  protracted,  or 
of  long  duration,  it  may  become  hypertrophied,  increased 
in  substance,  not  merely  depending  on  engorgement  for 
its  increased  bulk ; or,  it  may  become  indurated,  &c. 

In  recent  cases  of  engorgement  of  the  spleen,  it  may 
be  reduced  by  free  doses  of  quinine  (from  six  to  fifteen 
grains)  taken  three  or  four  times  a day.  The  bowels  in 
the  mean  time  should  be  kept  in  a soluble  condition  by 
the  use  of  mild  cathartics;  as  extract  of  white  walnut, 
&c.  If  the  quinine  should  act  on  the  bowels  in  the 
manner  of  a cathartic,  this  effect  should  be  controlled  by 
paregoric,  or  other  opiates.  According  to  one  writer, 
whom  we  have  heretofore  quoted,  the  cold  dash,  over  the 
region  of  the  spleen,  is  effectual  in  reducing  the  hy- 
persemic  condition  of  thisviscus;  and  th q general  cold  dash, 
in  curing  intermittent  fever.  If  the  patient  is  not  anaemic, 
but  of  a somewhat  florid  appearance,  rather  free  venesec- 
tion— but  not  often  repeated,  if  at  all  necessary  to  resort 
to  it  more  than  once;  and,  when  necessary,  with  an  inter- 
val of  several  days — may  be  of  considerable  service,  in 


ENLARGEMENT  OF  THE  SPLEEN,  ETC. 


153 


conjunction  with  the  quinine  and  cathartics  as  above  ad- 
vised. I have  noticed  the  engorged  spleen  diminish  in 
size  considerably,  in  a few  minutes  after  venesection.  A 
good  dose  of  quinine  should  be  given  shortly  after  the 
bleeding.  In  those  who  are  enfeebled,  or  of  a nervous 
temperament,  and,  perhaps,  in  others,  a teaspoonful  or 
two  of  sulphuric  ether  has  the  effect  of  reducing  the  en- 
gorged spleen  considerably,  within  a few  minutes  after 
it  is  taken;  but  I believe  this  is  not  likely  to  be  so  per- 
manent as  when  reduced  by  the  other  means  above 
mentioned. 

When  the  engorgement  is  more  protracted,  and  the 
ancemic  condition  ( splenic  cachexia)  is  manifest,  a combi- 
nation of  quinine  and  subcarbonate  of  iron  (quinine  grs. 
five  to  ten;  sub.  carb.  iron.  grs.  twenty  to  sixty;  which 
latter  may  occasionally,  for  a short  time,  be  alternated 
with  the  sulphate  of  iron)  should  be  given  three  times 
a day — which  may  be  taken  in  molasses,  or  otherwise. 
A mild  cathartic  may  be  given  every  third  night,  if  ne- 
cessary; but  constant  and  active  purging  should  be 
avoided  on  the  one  hand,  and  costiveness  on  the  other. 
Cupping  and  leeching  over  the  region  of  the  spleen  may 
be  of  some  service;  as  also  may  a couple  of  drachms  of 
quinine,  incorporated  with  mercurial  ointment  so  as  to 
make  a plaster,  which  may  be  worn  over  the  region  of 
the  spleen  for  a month  or  two ; but,  according  to  the 
writer’s  experience,  these  local  means  are  overrated. 
This  means  may  also  afford  relief  by  the  pressure  and 
support  it  gives  to  the  enlarged  spleen.  Or,  iodine  oint- 
ment may  be  rubbed  over  the  same  region,  once  or  twice 
a day.  But,  whatever  other  articles  are  used,  I would 
insist  particularly  on  the  protracted  use  of  large  doses  of 
subcarbonate  of  iron,  with  some  aromatic  or  stimulant  to 
make  it  agree  well  with  the  stomach ; such,  for  instance, 
as  powdered  capsicum,  pulverized  cinnamon,  and  the 
11 


154 


ENLARGEMENT  OE  THE  SPLEEN,  ETC. 


like.  It  may  be  well,  occasionally,  to  alternate  with 
other  preparations  of  iron;  as  the  tartrate  of  iron  and  po- 
tassa,  in  doses  of  from  fifteen  to  thirty  grains,  with  the 
capsicum  or  cinnamon  powders;  the  sulphate  of  iron, 
&c.  &c.  Dr.  Cartwright,  of  Natchez,  Mississippi,  speaks 
very  favorably  of  the  nse  of  cod  liver  oil  in  enlarged 
spleen;  and,  in  conjunction  with  some  of  the  ferruginous 
preparations,  it  is  no  doubt  well  adapted  to  this  abnormal 
condition  of  the  spleen,  and  also  to  the  cotemporary 
ansemic  condition  of  the  general  system.  A dose  of  the 
subcarbonate  of  iron  may  be  added  to  a tablespoonful  of 
the  oil,  and  taken  thrice  daily.  When  the  spleen  is  very 
much  enlarged,  well-adjusted  pressure  by  means  of  a 
bandage,  so  that  the  pressure  is  tighter  on  the  lower  side 
of  it,  may  afford  much  relief,  and  be  of  service.  If  the 
spleen  should  be  hypertrophied , the  ferruginous  treatment 
should  be  adopted,  as  above.  In  these  cases,  it  might  be 
well  to  insist  more  on  the  use  of  iodine  ointment  over  the 
region  of  the  spleen ; and  now  and  then  alternate  with 
the  other  preparations  of  iron,  the  iodide  of  iron,  inter- 
nally. The  iodine  ointment  may  be  rubbed  over  the  re- 
gion of  the  spleen  every  night,  but  a better  way  of  using 
it  is  by  spreading  it  on  a sufficiently  large  piece  of  buck- 
skin— near  the  edges  of  which  is  spread  Burgundy 
pitch,  so  as  to  make  the  plaster  stick — which  should 
be  worn,  and  renewed  every  few  days.  The  same  treat- 
ment is  proper  for  the  indurated  spleen.  If  the  indura- 
tion is  more  than  very  slight,  we  need  not  expect  to  en- 
tirely remove  it,  but  by  the  use  of  the  above  means  we 
may  improve  the  general  health.  The  diet  should  be  of 
a good  and  nourishing  kind,  and  moderately  indulged  in. 
It  should  be  somewhat  restricted  in  recent  cases  of  en- 
gorged spleen ; yet  the  system  should  be  properly  nou- 
rished. In  the  protracted  or  very  chronic  affections  of 
the  spleen,  of  whatever  nature,  if  there  is  much  anaemia 


LIVER— CHRONIC  ENLARGEMENT  AND  INDURATION  OF.  155 


present,  the  diet  should  be  liberal  and  of  good  quality; 
but  not  used  to  such  an  extent  as  to  oppress  the  stomach, 
or  cause  an  unpleasant  sensation  in  it  after  eating.  Fluid 
diet  disagrees  with  some.  Of  course,  in  cases  of  this 
kind,  the  diet  should  he  dry. 


CHAPTER  XI. 

LIVER— CHRONIC  ENLARGEMENT  AND  INDURATION  OF. 

Treatment. — In  similar  conditions  of  the  system  to 
those  noticed  when  treating  of  the  spleen,  above,  the 
chronic  enlargements  or  indurations  of  the  liver  require 
the  same  treatment:  i.  e.  the  protracted  use  of  iron,  iodide 
of  iron,  ointment  of  iodine  over  the  region  of  the  liver, 
and  aperients,  when  necessary  to  obviate  costiveness. 
In  these  cases,  the  preparations  of  mercury  have  often 
been  given  to  an  undue  extent,  increasing  the  cachectic 
condition  of  the  patient,  and  otherwise  acting  injuriously. 
If  the  case  is  recent,  the  complexion  of  the  patient  some- 
what florid,  an  occasional  dose  of  calomel  or  blue  mass 
may  be  of  service  ; but  in  the  chronic  from,  with  a pallid 
appearance  of  the  features,  or,  in  other  words,  when  the 
patient  is  anaemic , not  a few  constitutions  have  been  for 
ever  ruined  by  them.  This  is  one  form  of  disease,  in 
which  calomel  and  blue  mass  have  been  a great  curse  in 
the  malarious  regions  of  the  South. 


156 


NERVOUS  DISEASES. 


CHAPTER  XII. 

NERVOUS  DISEASES. 

In  the  different  neuralgic  affections , the  attendant 
pains  are  most  commonly  more  or  less  lancinating  and 
intense;  though,  not  unfrequently,  they  are  rather  ob- 
tuse : they  are  also  usually  relieved  by  pressure,  but 
in  some  cases  pressure  increases  the  pain ; — and,  when 
this  is  the  case,  we  should  be  careful  not  to  refer  the  pain 
to  inflammation,  as  this  might  lead  to  improper  treatment. 
Indeed,  the  persistent  irritation  in  a part,  for  some  time 
kept  up  by  nervous  derangement,  may  produce  inflam- 
mation, and  then  we  have  a double  indication  to  fulfil. 
One  important  characteristic  of  the  neuroses  generally, 
is,  that  they  are  nearly  always  periodical ; that  is,  they 
manifest  themselves  by  spells , with  longer  or  shorter  in- 
tervals ; though,  in  some  cases,  there  is  more  or  less  pain 
all  the  time  ; yet  they  have  their  periods  of  exacerbation 
or  increase,  which  may  last  for  a longer  or  shorter  time, 
say  less  than  an  hour,  several  hours,  or  longer,  and  then 
subside,  to  recur  again  about  the  same  time  the  next  en- 
suing day,  every  second  or  third  day,  or  at  longer  and 
irregular  periods,  as  once  in  a few  weeks,  or  months. 
Many  persons  are  subject  to  a nervous  headache,  which 
recurs  in  this  manner.  In  some  cases,  pain  over  one  eye 
{frontal  neuralgia ),  or  on  one  side  of  the  face,  recurs  in 
this  manner.  Indeed,  nervous  diseases  may  affect  any 
part  of  the  body,  though  commonly  they  are  more  apt  to 
affect  certain  parts  than  others.  When  the  stomach  is 
the  principal  location  of  the  pain,  it  is  called  gastralgia ; 


NERVOUS  DISEASES. 


157 


when  the  liver,  hepatalgia,  etc.  Spinal  irritation  is  per- 
haps more  or  less  connected  with  all  the  nervous  diseases 
which  affect  any  portion  of  the  body  or  limbs,  from  the 
neck  downwards.  It  is  a very  common  affection  in 
nervous  females,  and  may  be  either  primary  or  second- 
ary. It  is  frequently  observed  in  some  portion  of  the 
upper  half  of  the  dorsal  region,  between  the  shoulder 
blades.  When  speaking  of  chills  and  fever,  we  re- 
marked that  spinal  irritation  was  quite  common  in  this 
region  of  the  spinal  column,  especially  in  protracted 
cases,  or  after  the  chills  had  subsided.  In  these  cases, 
the  affected  portion  of  the  spine  is  found,  by  firm  pres- 
sure along  the  spinal  column,  especially  close  along  on 
either  side  of  it.  In  many  of  these  cases,  the  nerves, 
which  originate  from  the  region  of  the  spinal  marrow 
which  is  affected,  and  extend  around  the  sides  of  the 
chest,  also  participate  in  the  morbid  condition,  and  we 
then  have  dor so-inter costal  neuralgia , and  this  influence 
may  extend  to  the  liver,  stomach,  heart ; in  the  latter 
case  producing  palpitations,  etc.  etc.  ( See  pages  51  and 
52.)  When  the  uterus,  spleen,  &c.  ( see  pages  55,  56, 
and  165)  are  diseased  for  a length  of  time,  from  the 
constant  irritation  transmitted  to  the  spinal  marrow  in 
that  region  called  the  loins,  it  may  become  secondarily 
affected  ; the  origin  of  the  nerves  which  are  distributed 
to  the  lower  extremities  may  thus  become  affected,  and 
cause  pains  and  cramps,  or  cramps  in  different  parts  of 
the  lower  limbs,  or  hips ; or,  by  means  of  this  reflex 
action,  the  stomach,  head,  heart,  sides,  &c.,  may  mani- 
fest their  sympathies.  In  this  manner,  by  their  nervous 
connections  or  communications,  one  part  of  the  system 
sympathizes  with  another. 

Treatment. — In  the  treatment  of  the  different  neu- 
ralgic affections,  the  same  general  principles  are  appli- 


158 


NERVOUS  DISEASES— TREATMENT  OF. 


cable,  with  some  modifications  adapted  to  the  general 
condition  of  the  system,  and  the  part  or  parts  principally 
affected.  Of  course,  when  they  are  secondary,  are  pro- 
duced by  some  visceral  disease  or  local  irritation,  our  at- 
tention should  also  be  directed  to  the  removal  of  this 
latter  condition.  The  principles  of  treatment  laid  down 
heretofore  for  intermittent  fever , are  applicable  to  the 
neuroses  ; and,  therefore,  to  prevent  unnecessary  repeti- 
tion, I would  refer  the  reader  to  the  different  conditions 
noticed  in  the  treatment  of  that  disease,  requiring  modi-, 
fications  adapted  to  each,  and  request  a careful  examina- 
tion of  them.  For  instance,  if  the  complexion  of  the 
patient  is  rather  forid  than  pallid,  as  is  frequently  the 
case  in  those  who  are  afflicted  with  sick  headache,  or 
with  pains  in  sound  teeth  ( odontalgia ),  which  return 
periodically,  or  other  forms  of  neuralgia,  cpiinine,  or 
quinine  and  sulphate  of  zinc,  taken  two  or  three  times  a 
day,  with  opiates,  if  necessary,  for  temporal  relief,  and 
aperients,  to  obviate  costiveness,  will  generally  succeed 
in  curing  them.  If  the  neuralgic  affection  is  connected 
with  a pale , leucophlegmatic,  or  ancemic  condition , the 
free  use  of  iron,  as  the  subcarbonate,  with  quinine  or 
other  tonics,  will  be  necessary.  These  are  given  for  the 
purpose  of  effecting  a permanent  cure;  hut,  when  ne- 
cessary for  temporary  relief,  or  to  avert  a spell,  either  be- 
fore or  w-hen  the  premonitory  symptoms  show  themselves, 
opiates  should  be  given,  especially  if  the  intensity  of  the 
pains  demands  them.  Excessive  costiveness  should  be 
obviated  by  the  use  of  aperients;  such  as  the  extract  of 
butternut,  extract  of  dandelion  and  rhubarb,  tincture  of 
the  root  of  the  common  silk  wreed,  hlack  root,  &c.  &c. 
In  addition  to  the  articles  we  have  already  noticed  in  the 
treatment  of  intermittent  fever,  I would  also  refer  to 
others,  to  be  mentioned  farther  on  in  this  work.  ( See 
Gh.  XVI.)  If  there  is  any  cotemporary  visceral  disease, 


NERVOUS  DISEASES— TREATMENT  OF. 


159 


as  of  the  spleen,  liver,  stomach,  uterus,  &c  , the  reader 
is  referred  to  the  treatment  adapted  to  these.  In  these 
cases,  the  treatment  proper  for  the  removal  of  the  visceral 
disease,  is  also  proper  for  the  concomitant  neuralgic  affec- 
tion; which  latter  may,  however,  require  opiates  for  tem- 
porary relief;  but  they  should  not  be  indulged  in  too 
much  nor  too  long,  if  they  can  be  done  without,  conve- 
niently. As  the  visceral  disease  yields,  the  neuralgic 
affections  usually  subside. 

With  regard  to  external  medication , especially  in  the 
spinal  irritation  of  the  upper  portion  of  the  dorsal  region, 
a very  important  adjuvant  to  the  internal  remedies  is,  the 
cool  or  cold  dash  between  the  shoulders,  and  on  the  nape 
of  the  neck  and  head  ; or  a cool  or  cold  shower  bath,  espe- 
cially in  the  warm  or  mild  seasons  of  the  year.  If  the 
patient  is  too  feeble  to  bear  the  shower  bath,  the  body 
may  be  sponged  with  cool  water.  The  application  of  the 
water,  either  way,  should  commonly  be  attended  to  early 
in  the  morning,  or  on  an  empty  stomach.  Generally 
once,  and  sometimes  twice  a day,  is  sufficiently  often  to 
resort  to  this  external  application  of  cold  water.  If  ladies 
wrho  are  afflicted  with  nervous  diseases  of  this  nature, 
and  who  visit  the  “ Springs ” for  their  health,  would  at- 
tend more  frequently  to  these  directions,  they  would, 
no  doubt,  be  much  more  profited  by  their  visits  to 
these  places.  Inunction  with  iodine  ointment  along  the 
affected  portion  of  the  spine,  once  a day,  at  night,  per- 
haps, being  the  most  convenient  and  proper  time — or,  the 
ointment  may  be  spread  on  buckskin,  with  some  adhe- 
sive substance  (as  the  Burgundy  pitch,  or  adhesive  plas- 
ter), near  the  edges  of  it,  so  as  to  make  it  adhere;  the 
plaster  being  renewed  every  three  days — is  a remedy 
often  of  much  service.  Cupping  or  leeching  every  few 
days,  repeated  blistering,  the  application  of  tartar  eme- 
tic— sprinkled  on  a plaster  of  Burgundy  pitch,  so  that  it 


160 


EPILEPSY— PUERPERAL  CONVULSIONS. 


may  cause  pimples,  or  sores,  after  remaining  on  a few 
days,  which  are  then  allowed  to  heal,  and  the  tartar  eme- 
tic applied  again  and  again  in  this  way — frictions  with 
liniment,  pulverized  Cayenne  pepper,  mustard,  spirit  of 
turpentine,  opodeldoc,  narcotics,  the  application  of  the 
actual  cautery,  or  red-hot  iron,  &c.  &c.,  are  means  not 
unfrequently  resorted  to  with  advantage  ; but  these  should 
not  be  exclusively  relied  on,  to  the  neglect  of  means  ad- 
dressed to  the  general  system.  Free  out-door  exercise, 
and  everything  that  is  calculated  to  invigorate  the  sys- 
tem, should  receive  appropriate  attention.  The  diet 
should  be  nutritious. 

Epilepsy  is  most  commonly  of  a neuralgic  character, 
and  requires  the  same  treatment  as  above — with  the  ex- 
ception of  counter-irritation.  Some  years  ago,  the  author 
cured  a case  of  epileptic  fits , which  had  been  of  several 
years’  standing,  by  a combination  of  the  sulphate  of  qui- 
nine (three  grains)  and  sulphate  of  zinc  (one  grain),  three 
times  a day;  and,  every  third  or  fourth  night,  the  exhibi- 
tion of  an  aperient  dose  of  pills,  composed  of  calomel, 
rhubarb,  and  aloes,  for  a few  weeks.  It  occurred  in  the 
person  of  a lady  of  middle  age,  of  rather  slender  form, 
and  nervous  temperament.  There  was  dilatation  of  the 
pupil  of  one  eye.  The  internal  use  of  oil  of  turpentine, 
lunar  caustic,  and  many  other  articles,  is  recommended 
by  different  authors.  When  they  depend  on  mechanical 
injury,  a surgical  operation  may  be  demanded  for  their 
relief. 

When  any  of  the  neuroses  are  of  long  standing,  they 
usually  require  perseverance  in  a protracted  treatment. 

Puerperal  Convulsions. — Before  quitting  this  sub- 
ject— for  puerperal  or  child-bed  convulsions , occurring  in 
those  of  slender  frame,  lax  fibre,  and  nervous  tempera- 


NERVOUS  DISEASES— PUERPERAL  CONVULSIONS.  161 

ment,  I would  recommend  the  use  of  quinine  and  lauda- 
num, in  doses  of  eight  or  ten  grains  of  the  former,  and 
fifty  to  a hundred  drops  of  the  latter,  repeated  every  few 
hours,  lessening  the  dose  of  laudanum  till  the  system  is 
sufficiently  brought  under  the  influence  of  these  reme- 
dies. The  quinine  should  then  be  used  in  smaller  doses 
(four  or  five  grains)  three  or  four  times  a day;  and  the 
laudanum  as  occasion  requires.  If  the  patient  is  ancemic, 
subcarbonate  of  iron  and  quinine  should  subsequently 
be  made  use  of.  To  arrest  the  fits , in  addition  to  qui- 
nine and  laudanum,  ether,  in  one  or  two  teaspoonful 
doses,  may  also  be  given,  in  half  a glass  of  sweetened 
water ; some  of  it  may  also  be  breathed.  Subsequently,  to 
avoid  or  remove  costiveness,  aperients  should  be  given 
as  occasion  requires. 

It  may  be  proper  to  remark,  that  I can  quote  no  au- 
thors to  sustain  me  in  the  treatment  here  recommended  ; 
but  the  writer’s  experience,  founded  on  what  he  consi- 
ders correct  principles  of  medicine,  has  proved  its  suc- 
cess. It  is  an  almost  universal  practice  amongst  authors 
to  rely  principally  on  very  copious  abstractions  of  blood 
in  all  cases  of  this  affection.  This  is  certainly  a very 
great  erj;or.  In  those  of  sanguine  temperament  and  full 
habit , it  may  be  absolutely  necessary  to  resort  promptly 
to  free  venesection.  After  this,  I would  venture  to  re- 
commend a large  dose  of  quinine  (ten  or  fifteen  grains), 
and  sulphate  of  morphine  (one  grain);  and  the  liberal 
application  of  cold  water  to  the  head,  and  that  the  feet  be 
put  in  vcarm  water.  Active  cathartics  should  also  be 
given  in  cases  of  this  latter  kind.  For  this  dangerous 
affection , the  aid  of  a physician  should  always  be  sought, 
and  that  promptly,  too. 


From  my  limited  experience  with  puccoon  root,  I am 
inclined  to  think  favorably  of  its  influence  in  many  of 


162 


ATONIC  DYSPEPSIA. 


the  chronic  forms  of  the  neuroses.  The  dose  of  the  tinc- 
ture is  a teaspoonful  or  less,  three  times  a day,  either 
alone,  or  with  a solution  of  sulphate  of  zinc,  quinine,  &c. 


CHAPTER  XIII. 

ATONIC  DYSPEPSIA. 

The  general  condition  of  the  system  in  this  form  of 
indigestion  is  very  analogous,  if  not  identical,  with  that 
form  of  disease  which  we  have  already  noticed,  called 
chlorosis.  It  appears  quite  certain  that  they  are  identical. 
Youths,  girls,  and  young  men,  about  the  age  of  puberty, 
are  most  frequently  the  subjects  of  it,  according  to  the 
writer’s  experience,  which  he  believes  coincides  with 
that  of  others.  The  treatment  proper  for  chlorosis 
(which  we  have  already  noticed),  is  proper  for  atonic 
dyspepsia.  As  in  chlorosis,  the  patient  is  of  a pale,  tal- 
lowish  appearance,  and  is  easily  fatigued  by  sudden  or 
violent  exercise,  which  produces  hurried  respiration,  and 
a sensation  of  exhaustion  or  nervousness. 

Before  quitting  this  subject,  I will  remark  that  the 
excessive  use  of  coffee  is  a very  common  cause  of  dys- 
pepsia in  the  South ; and,  of  course,  in  cases  of  this  kind, 
its  use  must  be  greatly  modified  or  entirely  abandoned, 
in  order  that  a cure  may  be  effected.  The  excessive  use 
of  tobacco  may  be  mentioned,  as  another  cause  of  dys- 
pepsia. Many  cases  of  this  kind,  as  well  as  the  one  to 
be  mentioned  presently,  are  connected  with,  or  there 
exists  at  the  same  time,  spinal  irritation,  or  pain  between 
the  shoulders,  and  perhaps  some  form  of  nervous  affec- 


ATONIC  DYSPEPSIA, 


163 


tion,  as  pain  in  the  side,  shoulder,  head,  stomach,  etc., 
which  is  worse  at  some  times  than  at  others. 

In  the  treatment  of  cases  of  this  kind,  the  cause  should 
be  abandoned,  which  in  many  cases  will  go  far  to  afford 
relief;  but  as  the  general  health  will,  in  all  probability^, 
have  become  more  or  less  affected,  it  may  be  necessary 
to  use  some  of  the  preparations  of  iron,  with  some  vege- 
table tonic;  as,  the  subcarbonate  or  sulphate  of  iron, 
with  quinine,  extract  of  gentian,  or  the  like;  or,  if  the 
features  are  rather  florid,  the  Prussian  blue,  in  four  or 
five  grain  doses,  may  be  preferable;  to  which,  if  there 
should  be  concomitant  spinal  irritation  or  neuralgia,  a 
dose  of  puccoon  root  may  be  added,  or,  indeed,  in  many 
cases,  this  article  may  be  principally  relied  upon.*  To 
procure  temporary  relief  from  the  burning  which  some- 
times takes  place  in  the  stomach,  in  consequence  of  a 
superabundance  of  acid,  some  of  the  antacids,  or  alkalies, 
may  be  used,  as  supercarbonate  of  soda,  carbonate  of 
potash,  prepared  chalk,  ammonia,  ashes,  or  ley,  etc.  A 
good  preparation  for  this  purpose,  is  a solution  of  su- 
percarbonate of  soda  in  water,  and  enough  tincture  of 
cinnamon,  or  compound  tincture  of  cardamoms  added,  to 
render  the  taste  of  the  solution  pleasant.  The  diet  should 
be  regular,  somewhat  restricted,  but  nutritious. 

R.  Puccoon  root  (pulverized)  two  hundred  and  seventy  grains ; 
Prussian  blue  (pulverized)  two  hundred  and  seventy  grains  : 
Liquorice  (pulverized)  a sufficient  quantity. 

Make  into  one  hundred  and  eighty  pills.  Dose — two 
of  the  pills,  two  or  three  times  a day. 

The  other  form  of  dyspepsia,  to  which  allusion  was 
made  above,  consists  in  a chronic  inflammation  of  the 
stomach,  with  fullness  and  pain  at  the  pit  of  it,  the  pain 

* I notice  that  J.  L.  Mothershead,  M.  D.,  has  recently  cured  two  obsti- 
nate cases  of  dyspepsia,  by  the  use  of  the  puccoon.  Western  Lancet, 
May,  1849. 


164 


ATONIC  DYSPEPSIA. 


being  considerably  increased  by  pressure.  A hearty 
meal  is  apt  to  increase  the  pain.  In  these  cases,  or  at 
least  in  many  of  them,  the  features  have  a peculiar  florid 
appearance.  The  bowels  are  usually  costive,  in  some 
cases  obstinately  so. 

For  the  cure  of  these  cases,  lunar  caustic,  with  extract 
of  jimpson  {stramonium),  or  extract  of  henbane  ( hyoscy - 
amus ),  either  in  pills  or  solution,  is  probably  superior  to 
any  thing  else.  The  pills  may  be  made  as  follows : — 

R.  Lunar  caustic  (pulverized)  two  drachms; 

Extract  of  stramonium  two  to  two  and  a half  drachms  ; or, 
Extract  of  hyoscyamus  six  drachms  to  one  ounce. 

Mix  well,  and  make  into  one  hundred  and  twenty 
pills,  and  take  one  three  times  a day.  If  the  patient 
prefers  taking  these  articles  in  solution,  the  same  propor- 
tions as  above  may  be  added  to  a pint  of  water,  and  a 
teaspoonful  of  the  solution  (put  in  two  or  three  table- 
spoonfuls  of  pure  water  when  it  is  to  be  taken)  given  at 
a dose.  The  sulphate  of  zinc,  with  either  of  the  extracts 
above,  may  be  used  in  the  same  proportion  as  the  lunar 
caustic,  and  alternated  with  the  latter  every  wrnek  or  two, 
especially  if  discolorization  of  the  skin  is  apprehended; 
or  to  avoid  this,  if  it  should  be  necessary  to  use  the 
caustic  for  a long  time.  If  the  bowels  are  very  costive, 
a dose  composed  of  from  ten  to  twenty  grains  of  calomel, 
with  ten  or  fifteen  grains  of  rhubarb,  or  some  other 
aperient,  should  be  given  every  fourth  or  fifth  night,  or 
as  occasion  requires.  To  prevent  the  too  frequent  repe- 
tition of  the  calomel,  in  cases  which  are  very  obstinately 
costive,  a teaspoonful  of  the  following  may  be  taken, 
when  it  is  thought  proper. 

R.  Compound  spirit  of  lavender  two  fl.  ounces; 

Croton  oil  ten  or  twelve  drops. 

Iodine  ointment  may  be  rubbed  over  the  region  of  the 
pit  of  the  stomach  every  night  or  two  ; or  be  worn  on  a 


LEUCORRHCE  A , OR  WHITES. 


165 


buckskin  plaster,  made  by  putting  Burgundy  pitch 
around  the  edges.  These  cases  usually  require  the  treat- 
ment to  be  continued  for  months.  The  diet  should  be 
light,  easily  digested,  and  such  as  agrees  well  with  the 
stomach,  and  taken  in  but  small  or  moderate  quanti- 
ties at  a time.  Stimulants,  as  brandy,  etc.,  should  be 
avoided. 

In  that  form  of  dyspepsia  which  occurs  amongst  the 
opulent,  or  “high  livers,”  in  the  North,  in  Europe,  and 
elsewhere,  strict  attention  should  be  paid  to  dieting,  or, 
in  other  words,  living  on  abstemious  diet,  and  that  wrhich 
agrees  with  the  individual. 


CHAPTER  XIV. 

LEUCORRHCEA,  OR  WHITES. 

Whether  as  an  effect  or  cause  of  any  of  the  cachectic 
conditions  above  noticed,  whether  called  ancemia , chlo- 
rosis, etc  etc.,  leucorrhoea  is  well  known  by  the  physi- 
cians in  the  southern  States  to  be  one  of  the  most  common 
and  troublesome  maladies  to  which  females  are  liable ; in 
a good  many  of  which  there  is  a greater  or  less  degree  of 
falling  down  of  the  womb  ( prolapsus  uteri),  wdth  less  or 
more  attendant  chronic  inflammation  and  increased  size 
and  weight,  especially  of  the  neck  and  mouth,  of  this 
organ.  These  conditions  give  rise  to  unpleasant  sensa- 
tions of  weight,  bearing  down,  and  pains  in  the  region 
of  the  womb,  which  also  cause  pains  in  the  loins,  inside 
of  the  thighs,  or,  indeed,  by  reflex  action,  sympathies 
may  be  set  up  in  almost  any  part  of  the  system,  giving 
rise  to  various  forms  of  nervous  affections ; as,  hysterics, 
palpitations  of  the  heart,  faintness,  affecting  the  stomach, 


166 


LEUCORRHCE A,  OR  WHITES. 


head,  or  other  forms  of  neuralgia,  which  we  have  already 
noticed.  .These  and  other  diseases  of  the  uterus  entail 
more  protracted  ill-health,  suffering,  and  debility — to 
which  the  absurd  and  deleterious  practice  of  using  snuff 
often  largely  contributes;  not  unfrequently  ending  in  con- 
sumption, or  serious  diseases  of  the  womb,  and  finally 
death — on  females  in  the  South,  than  all  other  diseases 
put  together.  F rom  the  observations  of  the  writer,  whose 
experience  is  corroborated  by  southern  practitioners,  the 
most  prolific  source  of  these  different  morbid  affections 
of  the  uterus  is  want  of  proper  attention  in  parturition, 
either  from  neglect  or  improper  interference  of  ignorant 
or  unqualified  “ midwives ” I think  it  is  time  for  south- 
ern ladies  to  begin  to  look  to  their  own  interests  and. 
safety  in  these  matters,  and  more  generally  employ  com- 
petent physicians  during  their  “ confinement unless  the 
females  who  act  in  this  capacity  will  more  generally 
qualify*  themselves  for  midwifery  practice.  True,  these 
remarks  are  not  so  applicable  to  some  female  midwives 
as  to  the  large  majority  of  them ; some  having  taken 
pains  to  acquire  information  in  this  department : but, 
previous  to  assuming  this  responsible  position,  they 
should  place  themselves  under  the  instructions  of  com- 
petent medical  teachers,  and  devote  a sufficient  length 
of  time  and  study  to  acquire  that  knowledge  which 
will  enable  them  to  practice  “midwifery”,  with  safety  to 
others  and  with  credit  to  themselves.  I very  much  de- 
sire to  see  the  female  part  of  our  community  avoid,  as 
much  as  possible,  the  evils  above  noticed,  which  not 
only  detract  from  their  enjoyment  of  life,  but  cause  not 
a few  of  their  lives  to  be  more  or  less  unpleasant  or  mise- 
rable; and  finally,  after  less  or  more  protracted  suffering 

* It  appears  that  a Miss  Elizabeth  Blackwell  has  recently  obtained  the 
degree  of  M.  D.,  at  Geneva  Medical  College,  being  the  first  instance  of  the 
kind  that  has  ever  occurred  in  the  United  States. 


LEUCORRHCEA,  OR  WHITES— TREATMENT  OF. 


167 


and  distress,  to  reach  a premature  grave.  I hope  the 
above  remarks,  in  relation  to  a very  worthy  portion  of  our 
community  (female  mid  wives),  will  not  detract  from  their 
usefulness,  but  that  they  may  profit  by  these  suggestions 
and  become  more  really  useful. 

In  a warm,  relaxing  climate,  even  under  favorable  cir- 
cumstances, it  is  to  be  expected  that  these  diseases  will 
less  or  more  frequently  occur,  especially  in  those  who 
do  not  take  sufficient  and  active  exercise,  and  from 
improper  dressing,  as  tight  lacing,  and  a vast  amount 
of  unnecessary  clothing  about  the  hips,  in  accordance 
with  a fashion  I am  glad  to  see  is  passing  away. 

Treatment. — In  these  cotemporary  or  concomitant 
affections  of  the  uterus,  especial  attention  should  be  paid 
to  the  accompanying  cachectic  condition  of  the  system. 
For  this  purpose  the  ferruginous  preparations,  as  directed 
under  the  head  of  “ Cachexia , Treatment  of,"  should  be 
resorted  to,  and  other  means  calculated  to  invigorate  the 
system,  and  improve  the  general  health.  The  shower 
bath,  if  the  patient  is  not  too  feeble  to  bear  it,  or  if  so, 
sponging  the  entire  person,  and  free  out-door  exercise  in 
good  weather,  and  the  use  of  nourishing  diet,  are  means 
that  should  receive  due  attention. 

The  local  treatment  consists  in  the  use  of  various  as- 
tringent injections  into  the  vagina.  I have  found  a 
solution  of  chloride  of  lime  (bleaching  powder),  or  a 
solution  of  chloride  of  soda , diluted  so  as  to  produce  a 
gentle  not  unpleasant  wTarmth  in  the  vagina,  superior 
to  any  other  articles  which  I have  used,  in  this  manner, 
in  leucorrhoea.  The  proper  strength  of  these  solutions 
may  be  pretty  nearly  appreciated  by  taking  a small  quan- 
tity into  the  mouth.  The  vagina  should  first  be  washed 
out  by  tepid  water  and  soap,  thrown  up  by  means  of  a 
female  syringe.  She  should  then  lie  down,  with  her 


1(58 


LEUCORRHffiA,  OR  WHITES— TREATMENT  OF. 


hips  elevated  (which  may  be  done  by  placing  a cou- 
ple of  pillows,  or  other  articles  that  will  answer  the  pur- 
pose, under  them),  and  inject  one  of  the  solutions  freely 
into  the  vagina.  She  should  remain  in  this  position  for 
an  hour,  in  order  that  the  solution  may  remain  in  contact 
with  the  diseased  surfaces,  which  is  probably  most  fre- 
quently, and  particularly,  the  neck  of  the  womb.  This 
should  be  practiced  two  or  three  times  a day,  usually 
twice  may  suffice.  It  should  be  borne  in  mind  that  the 
treatment  general^  requires  to  be  persevered  in  for  a 
long  time.  If  this  fails,  perhaps  the  most  effectual  treat- 
ment is  the  application  of  the  solid  nitrate  of  silver  to  the 
neck  of  the  womb,  by  means  of  a speculum.  This 
should  be  done  by  a competent  physician.  Amongst 
other  astringents  which  are  frequently  used,  I may  men- 
tion solutions  of  sugar  of  lead,  sulphate  of  zinc,  and 
alum,  decoction  of  oak  bark,  &c.  &c.  If  there  is  much 
tumefaction  of  the  womb,  inunction  over  this  region,  or 
in  the  groins,  once  or  twice  a day,  writh  iodine  or  mercu- 
rial ointment,  is  often  of  considerable  service.  If,  at  any 
time,  there  should  be  considerable  uterine  pain,  opiate 
injections  into  the  vagina  may  contribute  to  afford  some 
relief.  Cupping  or  leeching,  over  the  region  of  the  loins, 
is  recommended  by  authors,  but  I believe  their  favorable 
influence  is  generally  overrated. 

We  have  already  remarked  that  the  patient  should 
persevere  in  the  use  of  the  preparations  of  iron,  internally. 
For  the  sake  of  convenience  to  the  reader,  I may  here 
observe,  that  the  following  formula,  alternated  every 
week,  with  some  of  the  other  formulas  above  referred  to, 
under  the  treatment  of  the  cachexia,  is  a very  good  one 
in  leucorrhcea : — 

R.  Subcarbonate  of  iron  five  drachms  ; 

Sulphate  of  iron  two  drachms  ; 

Cinnamon,  pulv.  four  drachms. 


WHITES— METRITIS— TREATMENT  OF. 


169 


Mix,  by  rubbing  well  together  in  a mortal.  Dose, 
from  fifteen  to  twenty-five  grains,  three  times  a day,  in 
syrup  or  molasses. 

If,  during  the  above  treatment,  an  acute,  or  subacute 
inflammatory  condition  of  the  uterus  (or,  indeed,  any 
other  part)  should  arise,  temporary,  but  not  too  active 
antiphlogistic  treatment,  should  be  resorted  to.  Vene- 
section, if  the  patient  is  not  too  feeble,  preferably  in  the 
foot,  two  or  three  doses  of  mercurial  cathartics,  combined 
with  rhubarb,  extract  of  butternut  &c.,  given  at  intervals^ 
of  twelve  or  twenty-four  hours  ; morphine,  if  necessary 
for  the  relief  of  pain;  the  semicupium  or  tepid  hip-bath ; 
and  bathing  the  feet  and  legs  in  hot  water,  are  the  means 
principally  to  be  relied  upon  for  the  reduction  of  this  in- 
flammatory condition  of  the  uterus.  The  French  re- 
commend the  direct  application  of  leeches  to  the  mouth 
of  the  womb,  which  may  be  done  by  the  use  of  the 
speculum. 

A blister  to  the  loins,  where  there  is  considerable  ach- 
ing, or  the  application  of  a flannel  cloth,  dipped  in  warm 
spirits  of  turpentine,  or  cupping,  may  afford  some  relief. 
Mercurial  ointment  should  be  rubbed  over  the  region  of 
the  uterus,  and  in  the  groins,  twice  a day,  for  several 
days;  and  then  iodine  ointment  used  in  place  of  it,  till 
the  metritis  (inflammation  of  the  womb)  subsides,  or  is 
perfectly  removed.  Warm  poultices  over  the  region  of 
the  womb,  just  above  the  pubes,  should  also  be  occasion- 
all)''  applied.  If  the  patient  is  very  feeble,  with  small, 
weak  pulse,  laudanum  should  be  given,  in  free  doses,  to 
allay  the  pain  in  the  womb  and  loins,  or  sick  stomach ; 
it  also  acts  favorably  in  assisting  to  remove  the  in- 
flammation. It  should  be  repeated  as  occasion  requires. 
Of  course,  in  the  meantime,  the  use  of  the  preparations 
of  iron  must  be  suspended,  till  the  metritis  has  greatly 
subsided.  If  there  is  considerable  debility,  and  the 
12 


170 


CHRONIC  METRITIS  AND  PROLAPSUS  UTERI. 


anaemic  condition  prominent,  the  use  of  iron  with  quinine 
may  be  commenced  earlier ; or,  indeed,  under  these  cir- 
cumstances, the  quinine  may  be  used  all  the  time.  When 
the  inflammation  has  considerably  subsided,  and  where 
there  is  any  doubt  as  to  the  propriety  of  the  resumption 
of  iron,  hydriodate  of  potass,  in  doses  of  from  three  to 
live  grains,  three  or  four  times  a day,  dissolved  in 
half  a glass  of  sweetened  water,  or  the  syrup  of  iodide  of 
iron,  may  be  taken  three  times  a day,  in  doses  of  from 
fifteen  to  twenty-five  drops,  in  sweetened  water. 

i 

Aperients,  as  .the  extract  of  white  walnut,  &c.,  should 
be  given  at  any  time  during  the  course  of  treatment,  if 
costiveness  demands  their  use.  The  leucorrhceal  dis- 
charge may  be  either  from  the  vagina  or  womb,  or  both. 
According  to  Dunglison,  Professor  Huston,  of  Philadel- 
phia, “ has  seen  more  advantage  from  injections  of  oil 
of  turpentine  than  from  any  other.”  It  may  be  prepared 
for  this  purpose,  as  in  the  following: — 

R.  Oil  of  turpentine  one  drackm 

Mucilage  of  gum  Arabic 

Water,  each,  one  and  a half  fl.  ounces. 

Mix,  and,  with  a female  syringe,  inject  into  the  vagina, 
twice  a day. 

The  cold  dash  to  the  loins  and  pelvis  may  be  of  service, 
repeated  once  or  twice  a day.  For  the  debilitated  con- 
dition of  the  system,  the  cold  shower  hath , or,  if  this  can- 
not be  used,  sponging  the  entire  person  with  cool  or  cold 
water,  once  or  twice  a day,  may  considerably  contribute 
to  restore  the  health  of  the  patient. 

In  Chronic  Metritis,  the  womb  is  enlarged  in  a 
greater  or  less  degree ; its  substance  is  more  dense,  and 
it  is  consequently  heavier  than  natural : hence  the  pro- 
lapsus uteri,  in  a greater  or  less  degree,  which  so  often 


CHRONIC  METRITIS  AND  PROLAPSUS  UTERI. 


171 


attends  this  condition,  and  the  pains  in  the  region  of  the 
womb — represented  sometimes  as  “ bearing-down  pains,” 
at  others  somewdiat  lancinating,  but  usually  rather  ob- 
tuse or  aching — the  loins,  inside  of  the  thighs,  and 
sometimes  elsewhere.  The  prolapsus,  or  coming  down 
of  the  womb,  is  in  many  cages  slight;  in  others  again, 
it  comes  still  lower,  and  in  some  presents  itself  at,  or 
even  external  to,  the  os  externum.  These  conditions 
cause  inflammation  and  ulceration  of  the  neck  of  the 
womb,  and  perhaps  the  vagina,  and  are  therefore  attended 
with  leucorrhoeal  discharges,  of  a whitish,  slightly  yel- 
lowish, or  sometimes  somewhat  greenish  appearance. 

In  the  South,  a large  majority  of  these  cases  are  accom- 
panied with  an  ancemic  condition  of  the  system  ; for  this 
variety,  the  treatment  has  already  been  given.  I should 
have  added  that  the  patient  should  lie  much  in  the  re- 
cumbent posture,  with  the  hips  elevated,  and  take  exer- 
cise by  rolling  about  on  a carpeted  floor.  These  direc- 
tions will  also  apply  to  the  other  variety,  for  which  we 
will  now  give  the  treatment.  The  distinction  which  I 
wish  to  make  here  is,  that,  in  this  variety,  the  complexion 
and  appearance  of  the  patient  is  florid,  usually  pre- 
senting more  or  less  fullness ; and  the  condition  of  the 
uterus  produces  more  or  less  febrile  excitement. 

At  the  commencement  of  the  treatment , if  the  system 
is  not  too  much  debilitated,  a moderate  venesection  may 
be  serviceable.  Whether  this  is  resorted  to  or  not,  oive 
an  emetic  of  tartar  emetic,  or  tartar  emetic  and  ipecac 
combined,  every  day;  and  four  or  five  grains  of  calomel 
every  night,  for  four  or  five  nights,  unless  it  should  act 
on  the  mouth,  and  then  every  other  night,  for  a wTeek  or 
two  (unless  it  should  affect  the  mouth) ; then  perhaps 
every  third  night,  or  every  fourth  night,  may  suffice. 
From  an  eighth  to  a quarter  of  a grain  of  tartar  emetic 
should  be  given  in  solution,  every  two  hours,  during  the 


172 


CHRONIC  METRITIS  AND  PROLAPSUS  UTERI. 


day.  When  the  febrile  excitement  of  the  system  has 
been  controlled  by  these  means,  which  also  modify  the 
local  inflammation,  and  when  the  features  begin  to  pre- 
sent a rather  whitish,  or  fair  appearance,  give  five  grains 
of  hydriodate  of  potash,  in  half  a glass  of  sweetened  water, 
three  times  a day.  Should  the  bowels  become  costive 
at  any  time,  three  or  four  grains  of  calomel  or  blue  mass 
may  be  given  at  bed-time.  Ointment  of  iodine  and  hy- 
driodate of  potash  should  now  be  rubbed  over  the  region 
of  the  womb  every  night.  Tim  diet  should  be  very  light. 
This  treatment  should  be  persevered  in,  be  the  time  long 
or  short,  till  a cure  is  effected.  As  before  remarked,  the 
recumbent  posture  should  be  mostly  maintained,  with  the 
hips  somewhat  elevated ; and  the  patient  should  mostly 
take  exercise  by  rolling  about  over  the  floor;  and  occa- 
sionally by  putting  the  feet  as  high  up  on  the  wallas  she 
can  conveniently.  This  means  will  tend  to  keep  the 
womb  in  its  natural  position,  and  favor  the  reduction  of 
the  inflammation.  If  the  prolapsus  is  very  slight,  more 
exercise  may  be  taken  on  foot.  In  those  cases  in  which 
the  womb  comes  down,  it  should  be  pushed  back  to  its 
natural  position.  The  leucorrhoeal  discharges  should  be 
washed  away  with  tepid  soap  and  water ; and  if  there  is 
any  burning  sensation  in  the  region  of  the  womb  or  va- 
gina, some  relief  may  be  obtained  by  injecting  a weak 
solution  of  sugar  of  lead ; to  which  may  be  added,  if  it 
be  severe,  from  thirty  to  sixty  drops  of  laudanum,  or  half 
a grain  of  the  sulphate  of  morphine. 


173 


DYSMENORRHCEA— TREATMENT  OF. 


CHAPTER  XV. 

DYSMENORRHCEA,  OR  PAINFUL  MENSTRUATION. 

Dysmenorrikea,  or  painful  menstruation , is  so  well 
known  by  those  who  have  suffered  with  it,  or  those 
who  have  been  called  upon  to  treat  it,  that  a descrip- 
tion here  would  be  unnecessary.  I may  remark,  how- 
ever, that,  at  each  return  of  the  catamenia,  there  is  a 
greater  or  less  degree  of  pain  in  the  womb,  which  is  in 
some  cases  most  intense.  There  is,  also,  pain  in  the 
loins  and  inside  of  the  thighs.  The  pain  is  most  severe 
during  the  first  two  or  three  days;  in  some  milder  cases 
not  lasting  longer  than  a day,  especially  if  proper  means 
are  used  to  control  it.  The  pains  are  now  and  then 
worse,  or  come  on  by  spells.  The  discharge  from  the 
womb  is  small  in  quantity,  more  especially  for  the  first 
two  or  three  days,  there  being  in  some  cases  clots  of 
blood,  and  sometimes,  also,  a whitish  membrane,  or 
whitish  shreds;  the  agony  of  the  patient  being  greatest 
as  these  are  forced  out  through  the  mouth  of  the  womb. 
In  some  cases  there  is  considerable  febrile  excitement. 

Treatment. — The  day  before  the  appearance  of  the 
menses,  the  female  should  take  a mild  cathartic;  as  the 
extract  of  white  walnut  and  calomel,  or  calomel  and 
rhubarb,  or  extract  of  black  root,  &c.  When  the  cata- 
menia make  their  appearance,  and  there  is  attendant 
pain,  give  about  six  grains  of  quinine  with  a quarter  of 
a grain  of  sulph.  morphine,  or  ten  grains  of  Dover’s 
powder.  If  there  is  much  febrile  excitement,  a mode- 
rate venesection,  preferably  from  the  foot,  may  be  neces- 


174 


DYSMENORRHEA— TREATMENT  OF. 


sary.  The  pain  should  be  controlled  by  opiates,  re- 
peated as  often  as  occasion  requires;  and  costiveness 
should  be  prevented  by  the  use  of  aperients.  Mercurial 
ointment,  rubbed  over  the  region  of  the  womb  twice  a 
day,  may  contribute  to  afford  relief. 

But  it  is  during  the  intervals,  or  the  time  that  inter- 
venes between  the  catamenial  epochs,  that  we  are  to 
expect  to  cure  this  disease.  The  treatment  during  this 
time  will  require  some  modification,  according  to  the 
condition  of  the  system.  In  many  cases  there  will  be 
found  to  be  more  or  less  ancemia ; which  will  require 
the  use  of  some  of  the  preparations  of  iron,  as  the  sub- 
carbonate, ten  to  twenty  grains,  with  quinine,  three 
grains,  and  from  forty  to  sixty  drops  of  the  tincture  of  the 
puccoon  root.  This  dose  should  be  taken  three  times  a 
day.  In  those  who  are  not  amemic,  the  puccoon,  either 
alone  or  combined  with  quinine,  or  the  following,  should 
be  given : — 

K.  Tincture  of  puccoon  root  fourteen  ounces ; 

Water  two  drachms; 

Sulphate  of  zinc  one  dracham. 

Dissolve  the  zinc  in  the  water,  then  add  the  solution  to 
the  tincture  of  the  puccoon.  Dose,  fifty  drops,  in  a wine- 
glass of  water.  Three  grains  of  quinine  may  be  put  in 
the  wine-glass  of  water,  before  the  above  is  added,  in 
obstinate  cases.  If  the  stomach  is  irritable,  a little  com- 
pound tincture  of  cardamom,  paregoric,  tincture  of  cin- 
namon, or  the  like,  may  be  added,  or  putin  the  mixture, 
before  it  is  taken.  In  cases  of  a rather  sanguineo-ner- 
vous  temperament,  the  following  acts  somewhat  favor- 
ably 

ft.  Water  eight  ounces; 

Hydri'od.  potas.  one  to  one  and  a half  drachm; 

Extract,  stramonii  fifteen  grains.  Mix. 

Dose,  one  tablespoonful,  in  half  a glass  of  sweet  or  pure 


DYSMENORRHCEA— TREATMENT  OF. 


175 


water,  three  times  a day.  If  the  extract  of  the  jimpson 
affects  the  head,  its  use  should  be  suspended  for  two  or 
three  days.  I would  recommend  that  a dose  of  the  puc- 
coon  be  taken  with  the  above,  if  it  should  be  used ; but 
the  puccoon  alone,  is  perhaps  superior  to  any  other  single 
article,  in  most  cases.  In  those  of  a full  habit  and  san- 
guine temperament,  a venesection  just  at  the  commence- 
ment of  the  catamenial  epoch,  for  two  or  three  periods, 
and  a mercurial  cathartic,  may  go  far  towards  controlling 
or  modifying  the  affection,  till  the  system  is  brought 
under  the  influence  of  the  other  remedies.  A very  good 
article  to  obviate  costiveness,  at  any  time,  is  the  extract 
of  white  walnut.  Dr.  McIntosh  speaks  favorably  of 
gradually  dilating  the  mouth  of  the  womb,  by  means  of 
silver  bougies,  of  different  sizes.  He  seemed  to  be  of 
opinion,  that  most  cases  of  dysmenorrhoea,  were  caused 
by  the  smallness  of  the  mouth  or  neck  of  the  w’ornb.* 
Though  this  may  be  true  in  many  cases,  it  is  far  from 
being  universal.  The  bougies  may  also  act  favorably 
by  the  pressure  on  these  parts;  but  if  used,  the  means 

* M.  Raynard  lias  presented  to  the  Acad,  of  Med.  of  Paris,  a memoir  on 
the  subject  of  Sterility  and  Dysmenorrhoea. , of  which  the  following  are  the 
conclusions:  1st.  The  cavity  of  the  neck  of  the  womb.. may  be  the  seat  of 

strictures,  congenital  or  accidental,  which  are,  to  a certain  extent,  analogous 
to  strictures  of  the  urethra.  2d.  These  modifications  in  the  structure  of  the 
uterus  induce  serious  disturbances  in  its  functions,  rendering  menstruation 
and  conception  painful ; and,  when  occlusion  is  complete,  impossible.  3d. 
This  state  of  the  uterine  neck  is  generally  indicated  by  a thick,  white,  vis- 
cid discharge.  4th.  This  condition,  by  keeping  up  continued  uterine  con- 
gestion, may  give  rise  to  serious  organic  diseases.  5 th.  Stricture  of  the 
uterine  neck  may  be  suspected  in  cases  of  dysmenorrhoea  and  sterility, 
which  cannot  be  otherwise  accounted  for.  6th.  The  treatment  of  urethral 
stricture,  is  equally  applicable  to  that  of  the  uterine  neck.  7th.  The  best 
treatment  consists  in  the  introduction  of  graduated  bougies,  by  means  of 
the  speculum,  and  allowing  them  to  remain  for  an  hour  or  two.  8th.  If 
this  should  fail,  we  must  have  recourse  to  incision  of  the  neck. — Prov.  Med. 
and  Sure/.  Journ.,  Jan.  1848.  See  also  Am.  Journ.  Med.  Sci.,  April  1848, 
p.  549. 


176  ARTICLES  FOR  THE  CURE  OF  INTERMITTENT  FEVER. 

above  should  also  be  attended  to.  If  there  should  be  any 
inflammation  of  the  womb,  or  ulceration  about  its  neck, 
with  leucorrhcea,  these  should  receive  appropriate  atten- 
tion. For  the  treatment  of  these  conditions,  see  the 
preceding  chapter. 


CHAPTER  XVI. 

ADDITIONAL  ARTICLES  FOR  THE  CURE  OF  INTERMITTENT 

FEVER. 

As  quinine,  even  in  very  small  quantities,  disagrees 
with  some  persons,  if  taken  into  the  stomach,  it  may  be 
used  endermically , after  removing  the  cuticle  by  a blister, 
by  mixing  it  with  a thin  paste,  made  of  flour  or  starch  ; 
for,  if  applied  alone,  it  causes  severe  pain.  When  used 
in  this  way,  it  is  said  not  to  produce  roaring  in  the  head, 
buzzing  in  the  ears;  or,  in  other  words,  it  is  said  not  to 
produce  quininism . For  young  children,  it  may  be 
rubbed  up  with  soft  ointment  or  lard,  and  rubbed  in  the 
armpits  and  groins. 

In  those  cases  in  which  quinine  disagrees,  it  may  be 
necessary  to  resort  to  other  articles,  some  of  which  are 
onsidered,  by  some  practitioners,  as  superior,  more 
effectual,  and  preferable  to  the  quinine,  without  being 
followed  by  unpleasant  effects.  We  will  notice  the  fol- 
lowing : — 

Dr.  H.  V.  Wooton,  of  Lowndesboro’,  Ala.,  speaks  very 
highly  of  the  ferrocyanate  of  quinia,  in  doses  of  from  two 
to  five  grains.  He  says  he  has  used  it  in  about  fifty 
cases,  and  has  found  it,  when  pure,  act  uniformly  without 
those  unpleasant  effects  which  arise  from  the  use  of  the 
sulphate  of  quinine,  whilst  it  is  just  as  certain,  and  more 


ARTICLES  FOR  THE  CURE  OF  INTERMITTENT  FEVER.  177 


powerful,  as  an  antiperiodic  remedy.  It  lessens  tlie  fre- 
quency of  the  pulse,  gives  tone  and  regularity  to  its 
action,  allays  nervous  irritation,  and  acts  as  a sedative 
and  diaphoretic. 

Dr.  Wooten  observes  : “ In  ordinary  cases  of  intermit- 
tent fever,  I cannot  see  that  its  effects  are  superior  to 
those  of  the  sulphate  (except  that  it  gives  no  uneasiness); 
and  as  it  costs  about  double  the  price,  I continue  to  use 
the'sulphate  in  most  cases  of  that  disease.  But  in  cases 
in  which  there  is  febrile  excitement,  or  inflammation, 
where  the  use  of  quinia  is  indicated,  I use  the  ferro- 
cyanate  altogether,  as  I find  it  more  certain  and  decided 
in  its  good  effects  than  the  sulphate,  and  not  liable  to 
produce  any  of  the  disagreeable  disturbances  of  that  salt. 
And  I may  add,  that  I use  it  with  full  confidence,  in  all 
cases  where  I wish  to  exert  a sedative  and  alterative,  or 
regulating  power  upon  the  nervous  system.”  This 
article  has  been  but  little  used  as  yet.  Some  others  speak 

favorablv  of  its  influence. 

•/ 

Clvinoidine. — Dr.  J.  S.  Unziker,  of  Cincinnati,  Ohio, 
prefers  this  article  to  the  sulphate  of  quinine.  He  says 
it  is  more  effectual,  and  the  fever  is  not  so  apt  to  return 
when  cured  by  it.  He  considers  it  particularly  suited  in 
cases  where  the  digestive  organs  are  not  much  debilitated. 
His  mode  of  giving  it  is  thus  : — 

B.  Chinoidine  twelve  grains  ; 

Ipecac.  . one  grain  ; 

Morphine  acet.  quarter  of  a grain. 

Mix,  and  make  into  six  pills,  to  be  given  in  two  doses, 
two  hours' previous  to  the  chills.  After  the  chills  have 
been  arrested,  he  would  give  a teaspoonful  of  the  tinc- 
ture (one  drachm  to  one  ounce  of  alcohol)  from  two  to 
three  times  daily,  in  some  claret  wine,  for  several  days. 


178  ARTICLES  FOR  THE  CURE  OF  INTERMITTENT  FEVER. 


Strychnine. — Daniel  Brainard,  M.  D.,  Professor  in 
Rush  Medical  College,  reports  83  cases  of  intermittent 
treated  with  this  article,  from  the  20th  of  February,  1846, 
to  1st  of  April,  1847,  with  the  following  results: — 


Cases  in  which  it  had  no  influence,  ...  14 

In  which  it  arrested  the  paroxysm  for  a week,  . 3 

“ “ “ “ “ two  weeks,  . 6 

Which  were  arrested  permanently,  ...  60 


83 

The  strychnine  was  given  in  one-eighth  grain  doses, 
thrice  daily,  till  one  grain  was  taken.  In  nearly  all  the 
cases,  quinine  had  been  given,  but  with  only  temporary 
relief.  Most  of  them  were  cases'of  long  standing  and 
frequent  relapses. 

The  influence,  or  medicinal  properties  of  Peruvian 
bark , are  so  well  and  generally  known,  as  not  to  require 
particular  notice.  When  given  to  arrest  intermittent  fever, 
it  should  be  mixed  with  capsicum,  powdered  cinnamon, 
or  some  other  aromatic  corroborant,  so  as  to  make  it 
acceptable  to  the  stomach,  and  given  in  large  doses,  like 
quinine,  with  intervals  of  three  or  four  hours.  It  may 
be  given  in  doses  of  from  two  scruples  to  two  drachms, 
so  as  to  take  three  or  four  doses  before  the  chill  time. 
After  arresting  the  chill,  it  may  be  taken  as  a tonic,  in 
from  ten  to  forty  or  sixty  grains,  three  times  a day.  The 
extract  of  Peruvian  bark  may  be  used  in  the  same  man- 
ner, in  doses  of  from  ten  to  fifty  grains.  Other  prepara- 
tions of  the  cinchona  are  sometimes  used. 

The  bark  of  the  willow  may  be  used  in  the  same  man- 
ner as  the  Peruvian  bark,  and  in  the  same  doses.  It 
may  be  conveniently  used  by  the  people  in  the  country, 


ARTICLES  FOR  THE  CURE  OF  INTERMITTENT  FEVER.  179 


in  decoction.  The  willow  grows  in  abundance  along  a 
great  many  streams  in  this  country.  A salt  lias  been 
obtained  from  the  willow  bark,  which  has  proved  suc- 
cessful in  many  cases  of  intermittent  fever.  It  is,  how- 
ever, inferior  to  sulphate  of  quinine.  It  is  called  salicin, 
and  may  be  taken  in  doses  of  from  two  to  ten,  or  fifteen 
grains,  three,  four,  or  five  times  a day. 

American  Holly  (Ilex  opaca). — A strong  decoction  of 
the  leaves  of  the  holly , or  hitters,  made  by  putting  the 
bruised  leaves  into  whisky  or  spirits  of  any  kind,  is  a 
remedy  that  is  too  much  neglected,  by  the  country  peo- 
ple especially,  as  it  is  so  easily  procured  by  them  without 
cost. 

Dogwood  ( Cornus  Florida). — May  be  used  in  the 
same  manner  as  the  holly.  The  bark  is  the  part  mostly 
used.  It  is  a good  tonic. 

The  smamp>  dogwood  (Cornus  cericea ),  either  the  bark 
or  the  leaves,  may  be  used  as  the  above. 

The  hark  of  the  wild  cherry  (primus  Virginiana),  or 
the  hark  of  the  common  poplar  (Liriodendron  tulipi- 
fera ),  may  be  combined  with  either  of  the  above. 

This  list  might  be  made  much  more  extensive;  but  we 
will  briefly  mention  the  following:  Boneset  (eupato- 

rium per foliatum),  extract  or  infusion;  common  yarrow, 
or  milfoil  (achillea  millefolium) ; gentian;  sulphate  of 
iron;  Prussian  blue,  in  doses  of  from  three  grains  to  five, 
or  more,  three  or  four  times  a day;  dose  for  a child,  one 
grain ; sulphur ; horehound  (marubium  vulgar e)\  a decoc- 
tion of  the  leaves  (fodder)  of  maize,  or  common  corn,  has 
been  used  in  some  places;  stimulants;  etc.  etc.  etc. 


180 


CONGESTIVE  FEVER. 


CHAPTER  XVII. 

CONGESTIVE  FEVER ; OR,  CONGESTIVE  CHILLS. 

Some  authors  object  to  the  term  “ congestive  fever” 
as  they  regard  it  an  improper  name  for  the  disease  we 
are  about  to  consider  : others  think  it  the  most  proper 
designation  that  could  be  given  it.  As  the  disease  is 
generally  known  by  this  appellation,  I will  not  enter  into 
a discussion  as  to  its  propriety  or  impropriety,  wishing 
rather  to  be  practically  useful  than  theoretical.  Notwith- 
standing a correct  and  uniform  nomenclature  is  desira- 
ble, I consider  it  a matter  of  no  very  great  importance, 
if  the  morbid  condition  is  correctly  appreciated,  and  the 
proper  treatment  adopted.  Other  names  have  been  ap- 
plied to  this  disease,  as  “ malignant  intermittent ,”  “ per- 
nicious intermittent ” “ intermittent  ataxic  fever”  and 
“ cold  plague” 

Unquestionably,  the  best  definition  of  congestive  fever, 
as  of  all  other  diseases,  consists  in  a description  of  its 
several  forms  and  modifications.  In  the  language  of  Dr. 
Harden,  “Disease,  abstractly  considered,  is  not  an  entity 
or  substantive  thing,  possessed  of  distinct  qualities  or 
properties,  by  which  it  may  be  distinguished  and  ar- 
ranged like  the  objects  of  natural  history,  but  rather  a 
mere  mode  or  condition  of  the  living  organism,  consist- 
ing  in  a certain  change  or  series  of  changes  in  the  solids 
and  fluids  ; the  external  manifestations  of  which  are  the 
phenomena,  whether  vital,  physical,  mechanical,  or  che- 
mical, presented  during  its  continuance,  or  after  the 
death  of  the  individual  subject  of  it.  The  difficulty, 
under  wdiich  the  nosologist  labors,  therefore,  may  be 


CONGESTIVE  FEVER. 


181 


appreciated  by  reflecting  that  the  classification  of  diseases 
is  but  a classification  of  modes  or  conditions  of  the  living 
system,  or  more  properly,  perhaps,  the  varying  'phe- 
nomena connected  with  those  conditions 

In  ctlmost  all  cases  of  congestive  fever,  premonitory 
symptoms,  analogous  or  identical  to  those  of  intermittent 
fever  precede  the  attack;  although,  in  rare  cases,  the 
attack  is  sudden,  and  the  shock  as  powerful  and  over- 
whelming as  though  the  system  had  received  a very 
severe  concussion  or  wound,  or  was  being  overpowered 
with  some_vioient  poison.  Sometimes,  though  very 
rarely,  an  individual  may  be  walking  about  apparently 
well,  and  fall  down  suddenly,  as  from  a fit  of  apoplexy. 
This  occurs  in  hot,  relaxing  climates,  in  which  intermit- 
tent, congestive,  and  remittent  fevers  are  endemic,  as 
in  Bengal,  Batavia,  India,  Italy,  the  more  southern 
portions  of  our  own  country,  and  elsewhere.  Dr.  Bell 
says  whan  he  was  at  Whampoa,  below  Canton,  he  saw 
a sailor  fall  down  on  the  deck,  within  a few  feet  of  him, 
senseless  and  motionless,  as  if  apoplectic.  He  recovered. 
On  board  of  another  vessel,  he  “ was  requested  to  visit 
incidentally  a man,  the  steward,  supposed  to  be  under  the 
influence  of  poison;  he  was  in  a state  of  insensibility, 
comatose,  with  occasional  slight  convulsions,  and  unable 
to  swallow.  He  had  been  in  this  state  since  the  preced- 
ing evening.  It  was  then  ten  o’clock  in  the  morning. 
External  stimulants,  and  an  enema  of  turpentine,  had  no 
effect.  He  died  before  noon.”  Dr.  R.  S.  Holmes,  Sur- 
geon in  the  United  States  Army,  in  Florida,  saw  two 
cases,  in  which  the  attack  was  sudden  and  powerful,  and 
which  terminated  fatally  in  less  than  twenty-four  hours. 
In  these  sudden  attacks,  the  individual  may  either  be 
very  much  prostrated,  dull,  stupid,  and  disinclined  to 
move,  or  he  may  be  restless,  rolling  to  and  fro  in  the  bed, 
perhaps  jumping  up  and  walking  about  over  the  house,  in 


182 


CONGESTIVE  FEVER. 


some  cases  becoming  giddy  ; then  staggers,  and  probably 
falls  on  the  floor.  Such  cases  are  apt  to  terminate  fa- 
tally, unless  prompt  relief  is  afforded.  Occasional  attacks 
of  intermittent  fever,  especially  after  the  system  has  be- 
come much  debilitated,  now  and  then  suddenly  assumes 
a very  severe  form  of  congestive  chill,  and  the  patient 
may  die  in  a few  hours. 

Fortunately,  the  species  of  cases  noticed  above  are  of 
very  rare  occurrence,  and  it  is  said  that  after  death  there 
may  be  no  lesion  of  any  vital  organ  to  account  for  this 
result.  In  one  of  those  violent,  restless  cases  reported  bv 
Dr.  R.  S.  Holmes,  and  which  terminated  fatally  in  less 
than  twenty-four  hours  from  the  time  of  attack,  the  pa- 
tient being  a stout,  vigorous,  dragoon  soldier,  the  post- 
mortem appearances  revealed  the  following : The  con- 
gestion was  in  the  thoracic  viscera.  “ The  viscera  of  the 
abdomen  were  in  apparently  a sound  and  healthy  condi- 
tion ; the  contents  of  the  cranium  were  in  a healthy 
state ; the  skin  around  the  whole  circumference  of  the 
chest  was  discolored  by  extravasated  blood  ; the  vessels 
of  the  heart  were  deeply  engorged  with  blood ; the  auri- 
cles and  right  ventricle  were  filled ; and  the  lungs  bled 
as  if  sponge  had  been  cut  that  was  soaked  in  blood ; the 
whole  blood  of  the  body  seemed  to  have  found  a common 
reservoir  in  the  thorax.” 

In  nearly  all  cases  of  congestive  fever,  the  attack  is 
precisely  like  that  of  intermittent  fever,  with  this  differ- 
ence ; in  the  former  it  is  more  intense : indeed,  conges- 
tive fever  is  only  a more  severe  form  of  intermittent 
fever;  the  nervous  system  being  more  profoundly  im- 
plicated, the  determination  to,  or  congestion  of  the  lungs, 
heart,  spleen,  liver,  etc.,  is  so  great  that  the  systein  is 
unable,  or  barely  able,  to  react  without  assistance.  There 
will  be  more  or  less  languor  and  debility,  oppression  and 
restlessness,  most  commonly  chilliness,  shivering,  and 


CONGESTIVE  FEVER. 


183 


shaking;  the  feet  and  hands,  arms  and  legs,  nose,  ears, 
and  face,  and  the  surface,  become  cold  and  benumbed ; 
with  exceptions  as  to  the  surface  surrounding  the  thorax, 
which  in  some  cases  is  of  the  natural  temperature,  or  of 
a morbid  heat,  which  in  some  instances  may  also  be  the 
case  with  the  head.  The  cheeks  are  usually  blanched 
and  more  or  less  purplish,  the  lips  pale  or  bluish,  the 
features  contracted  and  haggard,  eyes  perhaps  suffused, 
with  a wild  or  vacant  stare ; skin  pale,  with  more  or 
less  mixture  of  purple,  purplish  and  motley,  with  ecchy- 
moses  sometimes  in  dependent  parts,  and  shrivelled. 
The  sensibility  of  the  benumbed  extremities  is  impair- 
ed, and  the  general  surface  so  in  a less  degree;  in  some 
cases  the  patient  desires  his  benumbed  extremities  rubbed, 
in  order  “to  keep  up  the  circulation  in  them.”  The 
mouth  is  usually  cool  and  clammy,  and  the  tongue  more 
or  less  pointed,  pale,  or  of  a leaden  hue.  Impressions 
made  on  the  skin  by  mechanical  means,  as  by  the  finger, 
remain  for  some  seconds  after  the  pressure  is  removed. 
In  most  cases,  the  patient  complains  of  being  cold,  though 
in  others  no  coldness  is  complained  of ; this  latter  is  com- 
monly the  case  in  the  algide  form,  in  which  the  surface 
of  the  patient  feels  of  an  icy  coldness  to  another  person. 
Most  patients  complain  of  great  internal  heat,  are  thirsty, 
desire  cold  drinks,  and  their  room  freely  ventilated.  Some 
desire  to  have  their  breast  and  face  fanned,  and  perhaps 
sprinkled  or  sponged  with  cold  water.  In  some  cases, 
there  is  a cold  perspiration  about  the  forehead  and  tem- 
ples, which,  in  some  of  these,  extends  over  the  greater 
portion  of  the  body.  In  other  cases,  where  there  is  great 
restlessness,  a copious  sweat  occasionally  makes  its  ap- 
pearance, and  suddenly  or  soon  disappears.  The  pulse 
at  the  wrist  is  feeble,  very  compressible,  yielding  under 
very  gentle  pressure,  generally  increased  in  frequency 
(in  the  worst  cases,  Dr.  Holmes  has  not  seen  it  exceed 


184 


CONGESTIVE  FEVER. 


85  or  90;  Dr.  Lavender  has  seen  it  as  high  as  120  and  150), 
more  or  less  irregular,  and  in  some  cases  intermitting. 
Respiration  is  increased  in  frequency,  is  irregular,  with 
an  occasional  deep  inspiration,  or  sigh.  In  some  very 
severe  cases,  sometimes  convulsions,  singultus,  or  hic- 
cough, a feeling  of  suffocation,  heaving  of  the  chest  and 
laborious  breathing  occur.  In  some  cases,  especially  in 
the  algide  form,  the  patient  may  not  complain  of  any  pain 
at  all ; or  there  may  be  an  aching,  dull  pain  in  the  back, 
head,  and  limbs ; griping  pains  in  the  stomach  and  intes- 
tines, cramps  in  the  extremities,  etc.  In  many  cases, 
there  is  nausea,  irritability  of  the  stomach  and  vomiting, 
in  which  it  is  often  a very  difficult  matte!  for  the  stomach 
to  retain  anything;  even  cold  water,  which  the  patient 
drinks  with  avidity,  is  frequently  soon  thrown  up. 

Some  cases  of  congestive  fever  are  attended  with  coma 
and  costiveness ; others  with  copious  watery  evacuations 
from  the  bowels,  and  great  prostration.  I will  condense 
the  notes  of  a couple  of  cases  recorded  in  my  case-book, 
to  illustrate  each  of  these. 

Comatose,  somnolent,  or  lethargic  variety  of  congestive 

fever , attended  with  obstinate  costiveness. — Mr. , aged 

about  fifty-five,  farmer,  was  taken  with  this  variety  of 
congestive  fever  in  the  early  part  of  November  1S44. 
Before  I saw  him,  he  had  had  a paroxysm  which  lasted 
ten  or  twelve  hours,  during  which  time  he  was  somnolent 
and  insensible  to  all  surrounding  objects,  nor  could  he 
be  aroused.  When  I first  saw  him,  this  paroxysm  had 
passed  off,  and  he  conversed  some,  intelligibly,  though  it 
was  manifest  that  his  mental  faculties  were  dull.  I gave 
him  a dose  of  medicine  composed  of  quinine,  calomel, 
and  rhubarb;  but  it  was  but  a short  time  after  this  till 
another  congestive  chill  came  on,  with  concomitant  som- 
nolency, coma,  or  lethargy,  from  which  he  could  not  be 


CONGESTIVE  FEVER. 


185 


aroused;  occasional  stertorous  breathing;  eyes  nearly 
closed ; deglutition  most  of  the  time  could  not  be  per- 
formed; subsultus  tendinum;  cold  extremities,  &c.  A 
small  blister  having  been  made  on  the  nape  of  the  neck, 
quinine  and  sulphate  of  morphine  were  mixed  with  a 
little  thin  paste  made  of  flour  and  water,  and  applied  to 
it.  Stimulating  injections  were  repeatedly  used.  This 
paroxysm  lasted  about  as  long  as  the  previous  one;  after 
it  passed  off,  quinine  and  other  adjuvantia  were  promptly 
and  repeatedly  given,  which  averted  another  paroxysm, 
and  the  patient  recovered. 

Case  of  congestive  chill.,  with  copious  watery  discharges 

from  the  bowels. — Mrs.  , aged  about  twenty  years, 

mother  of  two  children,  youngest  about  ten  months  old, 
was  taken  with  a chill  and  diarrhoea  on  the  24th  (even- 
ing) of  March  1846.  On  the  morning  of  the  25th  she 
w\as  able  to  ride  a few  miles  to  visit  some  relatives,  and 
while  on  her  visit,  in  the  evening,  was  taken  with  a con- 
gestive chill,  attended  with  copious  and  very  frequent 
watery  discharges  from  the  bowels ; having  walked  out 
to  stool,  in  returning,  ere  she  reached  the  door  she  fainted, 
and  fell  prostrate  in  the  yard.  I saw  her  about  sun- 
set, faint,  very  weak,  and  prostrated  ; almost  incessantly 
getting  up  to  stool;  great  anxiety  and  oppression,  pulse 
very  weak,  increased  in  frequency,  extremities  cold,  &c. 
Gave  her  quinine,  laudanum,  and  paregoric;  repeating 
the  quinine  every  four  hours,  and  the  laudanum  and 
paregoric  as  occasion  required. 

26th. — The  quinine  affected  her  head  in  the  course  of 
the  night.  Ordered  it  to  be  given  in  smaller  doses,  with 
longer  intervals;  and  the  laudanum  and  paregoric  to  be 
given  as  occasion  required.  Recovery  without  another 
chill;  the  bowel  affection  also  arrested  and  cured.  I 
might  have  added,  that  this  case  was  also  attended  wdth 
13 


186 


CONGESTIVE  FEVER— DIFFERENT  FORMS. 


griping  pains  in  the  bowels,  aching  in  the  loins,  cramps 
in  the  lower  limbs,  &c.  This  form,  or  type,  appears  to 
be  analogous,  or  identical,  to  that  described  by  Hippo- 
crates, under  the  title  of  Asodes.  Dr.  T.  D.  Bell  (see 
page  15)  speaks  of  this  form  of  congestive  fever,  which 
prevailed  in  the  low,  flat,  marshy  country,  near  the  junc- 
tion of  the  Black  Warrior  and  Tombigbee  rivers,  in 
Alabama,  in  the  summer  of  1829.  Dr.  J.  B.  Wilkinson, 
of  Louisiana,  in  a communication  to  the  New  Orleans 
Medical  Journal,  in  the  July  No.,  1845,  speaks  of  such 
cases  occurring  in  his  practice.  (See  page  18.) 

In  many  cases,  attended  with  very  great  restlessness 
and  oppression,  the  patient  almost  incessantly  rolling  to 
and  fro  in  bed ; the  bowels  are  obstinately  costive,  seem- 
ing to  be  almost  insensible  to  the  influence  of  cathartics. 

In  the  algide  variety,  the  skin  is  as  cold  as  marble, 
wet  with  the  morning  dew;  the  action  of  the  heart  is 
feeble,  pulse  scarcely  perceptible ; there  may  be  no  thirst: 
vomiting  easily  excited ; mouth  and  tongue  pale,  cold, 
moist,  and  even  the  breath  is  cold  ; mental  faculties  com- 
posed ; the  patient  complains  of  no  pain ; if  dysentery  is 
conjoined,  the  eyes  sink  further  in  the  sockets,  look  hol- 
low, glassy,  and  are  surrounded  by  a purplish  hue. 

Some  authors  uselessly  make  many  varieties  of  con- 
gestive fever,  which  depend  on  the  predominant  symp- 
toms or  complications;  as  the  delirious ; gastralgic ; 
choleric ; syncopal;  carditic  ; hcemoptoic ; pleuritic  ; pneu- 
monic ; &c.  But  there  is  one  form  of  the  disease,  of 
which  I have  seen  no  account,  by  any  author.  I have 
seen  but  one  or  two  strongly  marked  cases  of  it  myself, 
but  have  heard  of  others.  My  esteemed  friend,  Dr. 
Murphy,  of  Decatur,  Alabama,  first  attracted  my  atten- 
tion particularly  to  this  form  of  congestive  fever.  He 
informed  me,  that  he  and  his  copartner,  Dr.  Dancy,  saw 
eight  or  ten  cases  of  it  in  the  summer  and  autumn  of 


CONGESTIVE  FEVER— DIFFERENT  FORMS. 


187 


1848,  all  the  subjects  being  adult  males.  This  variety 
is  characterized  by  a copious  perspiration,  which  is  cooler 
than  natural;  embonpoint  natural,  features,  body,  and 
limbs,  are  as  full  as  in  health  ; no  shriveling  of  the  skin, 
the  extremities  cold,  and  the  general  surface  cool;  great 
restlessness  and  oppression,  rolling  or  turning  from  side 
to  side;  usually  some  pain  in  the  head;  in  many  cases 
intense  gastric  distress,  and  perhaps  vomiting  of  a quan- 
tity of  ropy,  glairy  mucus,  in  some  cases  mixed  with 
bile,  or  streaked  with  blood,  or  both.  Dr.  Murphy  says, 
the  pulse  is  usually  about  fifty,  though  he  has  observed 
it  as  low  as  forty-five.*  Prostration  is  considerable,  and 
commonly  the  patient  imagines  death  almost  inevitable, 
requiring  the  encouragement  of  the  attendants,  and  the 
assurance  of  an  almost  certain  recovery.  Cases  of  this 
kind  may,  or  may  not  be  attended  with  dysentery.  As, 
so  far  as  I am  aware,  they  are  not  described  by  authors, 
an  abbreviation  of  the  notes  of  a case,  recorded  in  my 
case-book,  may  further  profitably  instruct  the  reader. 

Sept.  22d,  1848. — Mrs. , aged  39,  of  full  habit  and 

lax  fibre  ; enceinte,  and,  according  to  her  statement,  about 
seven  w'eeks  till  the  full  term  of  utero-gestation ; was 
usually  confined  at  about  eight  and  a half  months;  was 
the  mother  of  eight  or  ten  children.  In  the  twTo  last 
pregnancies  previous  to  this,  abortion  took  place  about 
the  seventh  month.  When  called  to-day,  I learned  that 
she  had  had  quotidian  intermittent,  for  several  days,  the 
chill  coming  on  about  four  o’clock  every  evening.  I 
found  her  with  the  chill  on,  attended  with  copious  and 
frequent  watery  discharges  from  the  bowrels,  griping  pains 
in  the  lower  part  of  the  abdomen,  great  gastric  distress, 

* Since  -writing  the  above,  I have  seen  a case,  white  male,  aged  forty-eight, 
in  which  the  pulse  varied  from  forty-eight  to  fifty-eight. 


188 


CONGESTIVE  FEVER— TREATMENT  OF. 


puking  of  a glairy,  ropy  mucus,  which  formed  a con- 
siderable bulk,  as  it  adhered  together;  and,  after  the  vo- 
miting continued  some  time,  the  mucus  was  mixed  with 
yellowish  bile,  and  tinged  with  blood.  Administered 
laudanum  and  quinine,  which  soon  gave  relief. 

Sept.  23 d. — Griping  pains  in  lower  part  of  abdomen ; 
abortion  suspected,  or  anticipated.  Ordered  injection  of 
laudanum  in  a little  starch  gruel,  which  gave  relief. 
Also  ordered  three  or  four  grain  doses  of  quinine,  four 
times  a day,  and  laudanum,  if  necessary. 

Sept.  25th. — Night  visit;  found  her  with  congestive 
chill;  extremities  cold;  the  general  surface  cool,  and 
covered  with  a copious,  slightly  clammy  perspiration, 
which  was  not  very  cold,  but  cooler  than  natural ; pulse 
scarcely  perceptible,  and  about  55  beats  in  a minute; 
great  gastric  distress;  vomiting  and  purging;  eyes  wild- 
looking, and  expressive  of  distress  ; great  oppression ; oc- 
casionally a deep  sigh,  and  a disposition  to  change  her 
position  in  bed  frequently.  She  seemed  to  think  that 
death  was  almost  inevitable  ; prostration  considerable. 

Treatment. — Gave  fifty  drops  of  laudanum,  with  ten 
grains  of  quinine,  and  shortly  afterwards,  one  teaspoon- 
ful of  sulphuric  ether,  which  gave  relief,  and  brought 
about  reaction.  Left  two  doses  of  quinine  for  her  to 
take  during  the  night,  and  ordered  three  or  four  grain 
doses  of  quinine  four  times  a day,  and  laudanum,  &c., 
as  occasion  required. 

Sept.  27th. — Early  this  morning,  was  informed  by  her 
husband  that  a small  quantity  of  blood  had  come  from 
the  genital  organs,  attended  with  pain  in  the  loins,  heavi- 
ness, and  bearing-down  sensations  in  the  region  of  the 
womb.  Abortion  feared.  Ordered  sugar  of  lead  and 
laudanum  internally,  and  opiate  injections.  P.  M. — 
Soon  after  supper  was  called  to  deliver  her — female  child 


CONGESTIVE  FEVER. 


189 


— dead — its  face  of  a leaden  hue,  as  though  it  had  been 
dead  some  time  ; the  mother  said  she  felt  it  move  early  in 
the  morning.  Tonic  treatment  was  adopted,  and  she 
soon  recovered. 

Dr.  S.  R.  Beatty,  of  Clear  Spring,  Washington  Co., 
Maryland,  gives  an  account  of  what  he  calls  “ congestive 
bilious  fever,"  which  occurred  in  his  practice  on  the  Po- 
tomac river  for  four  or  five  years  previous  to  1823,  or 
1829,  inclusive.  Notwithstanding  he  has  given  it  a 
wrong  name,  he  has  pretty  well  described  the  symptoms 
of  congestive  fever.  I will  quote  some  of  his  remarks, 
from  the  circumstance  that,  so  far  as  the  writer  is  aware, 
he  is  one  of  the  first  American  writers  who  well  de- 
scribes this  disease  separately  — we  can  scarcely  say 
separately,  as  he  considers  it  only  a modification  of 
bilious  fever ; yet  it  does  not  matter  about  the  name,  so 
the  symptoms  are  well  portrayed.  I also  make  the  ex- 
tract from  the  fact  that  he  recognizes  its  relation  to  the 
typhoid  pneumonia  of  this  country  (to  which  a chapter- 
will  be  devoted  in  the  latter  part  of  this  work),  and 
which  it  appears  a large  number  of  the  medical  world, 
even  at  the  present  day,  do  not.  But  to  the  extract. 

“The  congestive  bilious  fever,  from  the  coldness  of  the 
surface  which  attends  it,  and  its  fatality,  has  received  the 
vulgar  appellation  of  cold  plague  ; and  in  the  winter  and 
spring,  being  accompanied  with  pneumonic  symptoms, 
is  called  typhoid  pneumonia ; * * * * * the  malaria, 
and  the  exciting  causes  producing  the  congestive  form, 
are  of  a grade  so  overwhelming  and  deadly,  as  to  pros- 
trate at  once  the  action  of  the  heart  and  other  constitu- 
tional powers,  to  such  a degree  that  reaction  either  does 
not  take  place  at  all,  or,  if  it  does,  it  is  only  partial  or 
transient.  If  not  early  arrested  by  proper  treatment  it 
soon  runs  on  to  the  stage  of  collapse,  without  an  inter- 
vening one  of  excitement;  * * * the  surface  is  as  cold 


190 


CONGESTIVE  FEVER. 


as  marble,  particularly  on  the  extremities,  and  often  be- 
dewed with  a clammy  sweat;  the  patient,  at  the  same 
time,  complaining  of  great  heat  internally  ; in  some  cases, 
so  intolerable  as  to  cause  him  to  cry  out  that  he  feels  as 
if  a furnace  was  burning  within  him,  and  constantly  to 
be  calling  for  cold  water  to  relieve  the  intense  thirst  and 
internal  heat ; while,  at  the  same  time,  the  pulse  is  fre- 
quent, weak,  struggling,  and  unresisting.  The  attack 
often  comes  on  suddenly;  at  other  times  more  gradually, 
the  patient  first  complaining  of  lassitude,  as  in  other 
fevers;  the  extremities  then  become  cold ; the  stomach 
is  so  irritable  as  to  reject  everything  it  receives ; if  a 
glass  of  cold  water,  so  grateful  to  the  patient,  be  taken,  it 
is  immediately  thrown  up  ; if  medicine,  the  same  thing 
occurs.  There  is  great  anxiety  at  the  praecordia  ; pain 
in  the  head,  and  anxious  and  difficult  respiration.  The 
tongue  is  often  thickly  coated,  and  the  bowels  torpid  ; all 
the  secretions  being  either  totally  arrested,  diminished  in 
quantity,  or  of  a vitiated  quality.”  Dr.  Beatty  men- 
tions, that  some  cases  occurred  in  the  country  situations 
on  the  Potomac,  in  the  fall  of  1823,  with  yellowness  of 
the  skin  and  white  of  the  eyes,  and  such  violent  symp- 
toms “ as  would  have  ranked  them  amongst  the  worst 
cases  of  yellow  fever,  in  those  cities  where  the  disease 
mostly  prevails.”  In  further  describing  congestive  fever, 
Dr.  Beatty  remarks,  “ In  all  the  cases  of  congestion 
which  I have  met  with,  a symptom  occurred  which  I 
have  never  seen  noticed  by  any  author — a numbness  and 
deadly  feeling,  commencing  in  the  extremity  of  the  fin- 
gers and  toes,  and  proceeding  gradually  up  the  arms  and 
legs ; * * '*  the  patients  pointed  out  this  symptom,  and 
were  never  satisfied  unless  some  person  was  constantly 
rubbing  each  limb,  as  they  themselves  said,  ‘ to  keep  the 
blood  circulating.’  ” 

u Sometimes  partial  reaction  comes  on,  some  part  of 


CONGESTIVE  FEVER— TERMINATIONS.  191 

tne  body  or  the  head  becoming  preternaturally  hot.  If 
it  be  the  latter,  the  carotid  arteries  pulsate  strongly.  A 
general  excitement  may  emerge,  particularly  after  the 
action  of  proper  remedies,  and  the  disease  then  runs  its 
course  under  the  simple  or  inflammatory  form,  and  must 
be  treated  as  such.”* 

A very  large  majority  of  the  cases  of  congestive  chills 
are  preceded,  for  a few  days  or  longer,  by  common  chills 
and  fever,  or  ague  and  fever;  to  which  latter,  either  on 
account  of  neglect  or  maltreatment,  in  highly  malarious 
districts,  congestive  fever  ensues.  Some  years  ago, 
when  calomel  was  used  so  freely  in  the  southern  portion 
of  the  United  States,  congestive  fever  was  of  very  fre- 
quent occurrence  in  many  places  ; and  is  unquestionably 
much  more  frequent  at  present  in  those  regions  of  the 
southern  country  where  calomel  is  more  freely  used,  and 
the  old  antiphlogistic  treatment  adopted.  In  many  places 
in  the  South,  congestive  fever  has  almost  entirely  disap- 
peared, in  consequence  of  the  improved  mode  of  prac- 
tice; and  from  the  fact  that  the  people  in  the  country 
have  learned,  not  only  the  proper  means  to  cure  com- 
mon chills  and  fever,  but  also  the  importance  of  arresting 
these  before  they  are  merged  into  the  congestive  form. 
About  Courtland,  Alabama,  is  known  to  be  a highly  ma- 
larious region  of  country;  yet,  in  consequence  of  the 
applicability  of  the  above  remarks,  Dr.  Sykes,  of  that 
place,  not  long  since  informed  me,  that  congestive  fever 
was  now  of  rare  occurrence  there.  But  rather  than  be 
too  tedious,  I will  let  these  few  remarks  suffice. 

Terminations. — Very  few  cases  of  congestive  fever 
terminate  in  death,  if  the  proper  treatment  is  resorted  to 


* See  second  volume  Transylvania  -Journ.  of  Med.  for  1829. 


192 


CONGESTIVE  FEVER. 


in  time.  Though  it  is  a dangerous  malady,  if  left  to  it- 
self, it  usually  readily  yields  to  early  and  proper  treat- 
ment. I have  seen  a severe  case  treated  promptly  and 
efficiently,  and  the  patient  get  up  and  walk  out  and  at- 
tend to  some  light  business  on  the  same  day.  A remark- 
able case  of  this  kind  came  under  my  observation  in  the 
fall  of  1848;  and  as  the  notice  of  particular  cases  is  more 
impressive  and  instructive  than  general  remarks,  I will, 
for  the  benefit  of  the  reader,  take  some  notes  of  this  one, 
recorded  in  my  case-book,  and  enter  them  here.  This 
case  may  be  classed  with  that  variety  which  we  have  al- 
ready noticed,  and  which  we  considered  as  analogous  or 
identical  to  that  described  by  the  father  of  medicine, 
under  the  title  of  Asodes*  The  symptoms  of  these  cases 
are  very  analogous,  if  not  identical,  to  those  of  Asiatic 
cholera.  But  to  the  case. 

Mr.  IT,  aged  about  twenty-two,  was  taken  early  in  the 
morning,  on  the  10th  of  November  1848,  with  diarrhoea, 
which,  in  two  or  three  hours,  was  followed  or  accompa- 
nied by  a congestive  chill.  The  general  surface  was  of  a 
pale  leaden,  or  bluish  hue ; extremities  of  an  icy  coldness, 
and  the  general  surface  cool  and  dry ; features  contracted 
and  anxious;  shivering,  and  complained  of  being  cold — 
requested  a hot  rock  placed  to  his  feet;  great  anxiety  and 
restlessness ; would,  occasionally,  lie  in  one  position  for  a 
few  minutes,  with  now  and  then  a disposition  to  doze ; 
pain  in  the  head  and  back,  with  pain  and  cramp  in  the 
stomach  and  bowels  severe,  and  cramp  in  the  legs;  puked 
freely  and  repeatedly — water,  mucus,  and  blood  thrown 
up,  which,  after  a time,  was  tinged  with  yellowish  bile; 
purging  more  copious  and  watery.  Respiration  increased 
in  frequency,  irregular,  louder  than  natural,  labored,  with 
an  occasional  deep  sigh.  Pulse  feeble,  somewhat  irregu- 


* A Greek  word,  said  to  mean  “ anxiety,”  “ disgust,”  etc. 


CONGESTIVE  FEVER. 


193 


lar,  about  ninety  per  minute;  very  thirsty,  desiring  cold 
water  every  few  minutes.  Treatment  commenced  at 
about  half-past  nine  o’clock,  the  chill  having  been  on 
near  two  hours.  I gave  him  about  eight  grains  of 
quinine  and  forty-five  drops  of  laudanum,  which  were 
thrown  up  in  about  ten  minutes,  and  then  the  dose  was 
repeated;  which,  after  retching,  or  efforts  at  vomiting, 
relieved  the  severe  pain  of  the  stomach,  and  otherwise 
gave  relief.  After  I discovered  that  reaction  was  gra- 
dually taking  place,  I left;  having  given  directions  to 
repeat  the  quinine  and  laudanum  again,  if  that  I had 
given  should  be  thrown  up.  Also  ordered  quinine  and 
paregoric  to  be  taken  at  night,  and  the  ensuing  morning ; 
and  quinine  in  smaller  doses  three  times  a day  for  seve- 
ral days,  and  opiates,  as  occasion  required,  to  control  the 
bowel  affection,  -&c. 

Nov.  llth.  Saw  my  patient  walking  about  town  to-day. 
He  informed  me  he  was  up  walking  about,  about  an  hour 
after  I left  him  yesterday,  which  would  make  it  about 
noon.  He  said  he  had  very  little  fever. 

Notwithstanding  the  severity  and  danger  of  congestive 
fever,  if  left  to  itself,  the  treatment  of  this  case  shows  how 
promptly  and  certainly  it  yields  to  early  and  proper  treat- 
ment. And  the  analogy  between  this  form  of  congestive 
fever  and  Asiatic  cholera,  inclines  me  to  believe  that  the 
same  mode  of  treatment  adapted  to  the  former,  if  early 
resorted  to,  would  be  equally  successful  in  the  latter. 

If  a case  of  congestive  fever  proceeds  on  to  a fatal  ter- 
mination, in  the  language  of  Charles  E.  Lavender,  M.D., 
of  Selma,  Alabama,  “he  lies  still,  it  may  be  for  a minute, 
without  breathing,  then  gasps  for  breath,  makes  short  and 
hurried  respiration,  cries  that  he  shall  die  for  want  of 
breath;  rises,  advances  hurriedly  to  the  window,  stag- 
gers, throws  himself  on  another  bed,  or  falls  on  the  floor; 
the  pulse  has  ceased  to  flutter  at  the  wrist;  a moment’s 


194 


CONGESTIVE  FEVER. 


unusual  anguish,  a gasp  or  two  for  breath,  the  heart 
ceases  to  beat,  and  death  closes  the  scene  in  six  or  emht 
hours  from  the  access,  the  sufferer  retaining  his  senses  to 
the  last.  At  other  times,  death  approaches  under  cover 
of  a deep,  comatose  sleep,  of  several  hours’  duration. 
Sometimes,  though  rarely,  the  paroxysm  closes  in  con- 
vulsions. 

“ The  fatal  moment  is  sometimes  delayed  a few  hours 
by  the  free  use  of  diffusible  stimulants,  in  which  case  the 
patient  usually  dies  comatose.  At  other  times,  partial 
reaction  takes  place;  the  skin  becomes  wTarm,  or  even 
hot;  extremities  remaining  cold;  pulse  may  again  be 
counted;  from  150,  it  falls  to  120  ; it  may  be  the  patient 
sleeps  for  some  hours,  or  dozes  on  in  painful  and  inter- 
rupted slumbers,  to  be  followed  the  next  twenty-four 
hours  by  another  paroxysm,  terminating  in  fatal  collapse.” 
The  coldness  of  the  extremities  becomes  more  and  more 
permanent,  and  gradually  encroaches  upon  the  body  ; 
the  feet,  legs,  hands,  and  forearms,  first  being  of  a 
deathlike  coldness ; then  the  thighs,  arms,  head,  face, 
and  so  on  to  the  body,  till  life  becomes  extinct.  In 
some  cases,  for  some  time  prior  to  dissolution,  the  sur- 
face is  covered  with  a copious,  cold,  clammy  perspira- 
tion. 

If  the  paroxysm  is  less  severe,  it  may  be  followed  by 
complete  reaction,  and  rapid  convalescence  may  ensue; 
or,  if  the  reaction  is  less  complete,  a severer  paroxysm 
may  come  on  in  the  next,  twenty-four  hours,  and  termi- 
nate in  death;  or,  it  may  be  less  intense,  followed  by 
more  perfect  reaction,  and  the  patient  may  soon  be  re- 
stored to  health;  or  it  may  run  into  the  remittent  or  in- 
termittent form  of  fever.  If  it  proceeds  on  to  the  third 
chill  or  paroxysm,  it  is  said  generally  to  terminate  fatally  ; 
though  this  is  not  always  the  case;  yet,  the  third  chill 
is  very  much  dreaded  by  practitioners,  and  the  people. 


CONGESTIVE  F-EVER— TERMINATIONS. 


195 


In  their  recurrence,  the  paroxysms^  I believe,  usually 
obey  the  quotidian  type — sometimes  the  tertian.  Dr.  R. 
S.  Holmes  remarks,  that  the  congestion  in  congestive 
fever,  is. not  “brought  on  purely  by  the  time  of  the  pa- 
roxysm ; any  quick,  exciting  cause,  be  it  ever  so  trivial, 
the  entrance  of  a stranger,  the  firing  of  a gun,  some  one 
bursting  suddenly  into  the  room,  even  the  visit  of  the 
physician,  will  throw  the  blood  from  the  extremities,  or 
more  properly,  perhaps,  prevent  its  due  propulsion  into 
them;  the  lips  will  become  livid,  the  tip  of  the  nose  and 
ears  cold,  the  feet  and  legs  cold,  the  cheeks  blanched ; 
and  yet  the  patient,  strange  to  say,  will  be  unconscious, 
generally,  that  a change  has  come  over  him ; all  this,  too, 
independent  of  the  regular  periodic  time,  when  the  true 
paroxysm  comes  on.” 

Dr.  Lavender  says  : “ Of  all  the  local  congestions  that 
attend  upon  this  form  of  disease,  that  of  the  brain  is  most 
alarming,  least  manageable,  and  most  fatal.  It  is  marked 
by  deep  coma,  low,  muttering  delirium,  rolling  the  head 
on  the  pillow,  a drawing  of  the  head  backwards,  dilata- 
tion of  pupils,  optic  illusions ; and,  if  partial  reaction 
takes  place,  raging  delirium  may  come  on.”  Engorge- 
ments, and  consequent  enlargements  of  the  spleen,  etc. 
etc.,  are  well  known  to  be  of  common  occurrence  in  con- 
gestive fever,  but  these  will  be  noticed  when  we  come  to 
treat  of  its  pathology,  and  refer  to post-mortem  examina- 
tions. 

In  the  intervals,  or  between  the  paroxysms,  Dr.  Holmes 
observes:  “He  will  be  torpid,  morose;  his  mind  dull, 
slow  in  gathering  up  his  thoughts,  his  pulse  laboring, 
and  full  and  slow, Jus  bowels  sluggish,  or,  if  irritation  has 
set  in  upon  them,  frequently  purged  ; the  secretions  from 
his  liver,  kidneys,  and  skin,  improperly  carried  on,  or 
almost  checked ; if  the  congestion  is  on  the  brain,  he 
will  complain  of  dull  pain  in  the  head,  if  on  the  thorax, 


196 


CONGESTIVE  FEVER— PATHOLOGY. 


his  breathing  will  be  hastened,  if  on  the  abdomen,  in- 
flammation of  the  intestines  will  probably  soon  set  in,  if 
the  disease  is  not  speedily  checked.” 

As  to  the  causes  of  congestive  fever,  the  reader  is  re- 
ferred to  the  first  part  of  this  volume,  and  also  to  a few 
remarks  made  on  page  191. 

Pathology. — It  appears  that  the  primary  morbid 
impression  is  perfectly  identical  with  that  of  intermit- 
tent fever,  with  the  difference  that,  in  congestive  fever, 
it  is  much  more  intense.  As  remarked  when  treating 
of  the  former,  for  aught  we  know,  previous  to  the  chill, 
there  may  be  a link  in  the  chain  of  morbid  action,  con- 
sisting in  a modified,  altered,  or,  in  other  words,  morbid 
condition  of  the  blood  ; yet,  apparently,  the  first  great  or 
primary  morbid  impression  is  made  on  the  nervous  sys- 
tem. The  precise  nature  of  this  impression  is  not  known, 
though  it  would  appear  to  be  a sedative  or  debilitating 
one,  which  prevents  the  great  nervous  centres  from  se- 
creting or  generating  a sufficiency  of  nervous  fluid,  or 
that  which  gives  nervous  power,  or  power  to  the  nervous 
system  ; hence,  the  heart,  lungs,  etc.,  not  receiving  that 
amount  of  nervous  influence  which  will  enable  them  to 
carry  on  or  perform  their  functions  normally ; or,  more 
properly,  on  account  of  nervous  debility,  their  functions 
are  impaired,  and  they  become  congested,  engorged  with 
the  circulating  fluid,  the  blood.  So  far  as  we  are  capable 
of  judging  from  symptoms,  it  appears  that  the  morbid 
impressions  made  on  the  three  great  nervous  centres  do 
not  always  bear  the  same  relation  to  each  other  in  diffe- 
rent cases;  as,  for  instance,  the  undisturbed  condition  of 
the  intellectual  faculties  in  the  algide  form,  and  even  a 
repose  which  is  said  to  be  agreeable  to  the  patient, 
which  may  be  regarded  as  an  evidence  that  the  brain  is 
less  affected  than  the  spinal  and  ganglionic  systems  of 


CONGESTIVE  FEVER — PATHOLOG V. 


197 


nerves,  though  the  absence  of  pain  in  the  former  does  not 
necessarily  imply  that  it  is  not.affected  at  all ; yet,  while 
the  brain  maintains  its  functions,  this  is  an  evidence  that 
it  is  but  slightly,  if  at  all,  morbidly  affected  : however, 
even  t®§  feeling  of  repose  may  be  an  evidence  of  morbid 
impression.  Other  cases  are  attended  with,  coma  or  le- 
thargy, or  raging  delirium,  which  unmistakably  inform 
us  of  the  serious  implication  of  the  brain.  In  others, 
again,  we  observe  that  the  spleen,  stomach,  and  bowels, 
heart,  etc.,  are  most  prominently  affected,  an  evidence  of 
the  greater  implication  of  the  ganglionic  or  organic  sys- 
tem of  nerves  ; but  as  all  parts  of  the  nervous  system  are 
so  intimately  connected  with  each  other,  and  so  mutually 
dependent  on  one  another,  when  one  is  much  affected, 
the  others  will  participate  in  a greater  or  less  degree. 
Post-mortem  examinations  also  go  to  justify  such  conclu- 
sions as  these;  pathological  lesions  in  some  cases  being 
most  prominent  in  the  head,  in  others  in  the  thorax,  and 
in  others  in  the  abdomen.  In  the  case  we  have  hereto- 
fore noticed  (examined  by  Dr.  R.  S.  Holmes,  when  he 
was  army  surgeon  in  Florida),  the  viscera  of  the  abdo- 
men and  contents  of  the  cranium  were  in  an  apparently 
healthy  condition,  the  heart  and  lungs  being  deeply  en- 
gorged with -blood.  The  pathological  lesions  observed 
by  M.  Bailly,  who  visited  Rome  for  the  purpose  of  endea- 
voring to  ascertain  the  nature  and  seat  of  this  disease,  go 
also  to  prove  that  they  are  not  uniform.  In  36  necrosco- 
pies, as  given  by  Bell,  the  records  are  as  follows  : arach- 
nitis, 25 ; gastro-enteritis,  19 ; splenitis,  18  ; rupture  of 
the  spleen,  3 ; diffluent  spleen,  2 ; cephalitis,  13  ; gastri- 
tis, 7 ; enteritis,  7 ; alterations  of  the  liver,  5 — of  which 
one  wTas  by  inflammation,  two  by  congestion,  and  two  by 
putrilaginous  softening  ; pneumonitis,  3 ; pericarditis,  3 ; 
peritonitis,  2 ; parotiditis,  1 ; oesophagitis,  1 ; cystitis 
(biliary),  1. 


198 


CONGESTIVE  FEVER— PATHOLOGY. 


Some  writers  consider  the  phenomena  of  congestive 
fever  to  be  induced  by  irritation  of  the  cerehro-spinai 
axis ; others,  that  the  ganglionic  system  suffers  most 
severely  ; so  far,  then,  as  opinions  are  -worth  anything, 
they  go  to  prove  the  remarks  already  made. 

Unfortunately,  heretofore,  the  minds  of  physicians 
have  been  too  much  directed  to  the  circulation  of  the 
blood,  and  pathologists  have  been  too  exclusively  hunting 
after  some  local  or  organic  disease,  to  the  neglect  of  the 
nervous  system,  and  its  functions.  The  folio-wing  re- 
marks of  Dr.  S.  R.  Beatty,  will  serve  pretty  well  to  give 
an  idea  of  the  disturbances  of  the  circulation;  but,  un- 
fortunately, his  mind  is  too  exclusively  directed  to  this, 
an  effect,  without  looking  to  the  cause  of  it,  the  morbid 
condition  of  the  nervous  system.  He  says,  the  cause  or 
causes  “ are  so  deadly  and  overwhelming,  as  almost  com- 
pletely to  prostrate  the  action  of  the  heart ; a more  exten- 
sive congestion  takes  place  about  its  right  side,  than  in  the 
other  two  varieties  [simple  and: inflammatory  fevers],  and 
its  muscular  parietes  are  so  much  distended  by  this  un- 
natural engorgement  as  to  be  almost  paralyzed ; for  the 
same  reason  that  the  contractile  muscles  of  the  hand  or 
mouth,  or  any  other  part,  when  they  are  stretched  to 
their  utmost  extent,  have  not  near  so  powerful  a contract- 
ing force,  as  wdien  they  are  only  moderately  extended. 

, “ The  heart,  therefore,  in  this  fever,  has  not  the  power 
of  producing  a general  excitement,  as  in  the  two  former ; 
but  efforts  towards  it  are  sometimes  made,  the  tempera- 
ture of  the  chest  or  abdomen  being  raised  considerably 
above  the  natural  standard  ; while  the  other  part  of  the 
body  remains  of  a deathlike  coldness,  bedewed  with  a 
clammy  sweat,  and  the  pulse  at  the  wrist  scarcely  per- 
ceptible, the  powers  of  the  heart  being  still  too  weak  to 
extend  its  influence  so  far  from  the  centre  of  circulation. 
This  attempt  at  reaction  generally  vanishes  in  a short 


CONGESTIVE  FEVER— PATHOLOGY.  199 

time,  the  heart  being  too  much  oppressed  by  the  internal 
engorgement  to  accomplish  it,  and  the  disease  passes  on 
to  the  stage  of  collapse,  and  terminates  in  violent  cases 
as  soon  as  the  third  day ; in  others,  it  lasts  nine  or  ten 
days,  or  even  longer.  The  congestion,  commencing  in 
the  right  side  of  the  heart,  extends  up  the  descending 
cava  into  the  sinuses  and  veins  of  the  brain,  producing 
the  sense  of  fullness  of  that  organ,  coma,  delirium,  &c. 
In  the  thorax,  the  blood  returning  from  the  vena  azygos, 
and  through  it  from  the  bronchial  veins,  being  obstructed 
by  the  accumulation  in  the  descending  cava,  and  the 
congestion  of  the  right  ventricle  extending  into  the  pul- 
monary arteries,  oppress  the  lungs,  and  thereby  cause 
that  anxious  respiration  and  sense  of  suffocation  which 
invariably  attend  this  disease. 

“ It  is  now  plain,  that  in  the  congestive  state,  too  large 
a proportion  of  blood  is  accumulated  in  the  veins  and 
right  side  of  the  heart,  and,  of  consequence,  too  small  a 
quantity  remains  in  the  left  side  and  arteries.  This  state 
explains  the  cause  of  the  extreme  feebleness  of  pulse  and 
general  coldness  of  the  surface,  the  characteristic  symp- 
toms of  congestion.” 

This  country  has  for  many  years  past,  and  is  still,  but 
to  a less  extent,  cursed  with  an  ingenious,  false,  delusive, 
and  fatal  theory,  in  referring  all  our  fevers  to  disease  of 
the  liver,  and,  consequently — as  the  advocates  of  this 
theory  contend — demand  the  liberal  use  of  calomel!  ! I 
am  sorry  to  see  that  there  are,  even  yet,  not  only  men  who 
stand  high  in  the  medical  profession,  but  even  profes- 
sors and  teachers  in  medical  schools,  under  the  influ- 
ence of  this  delusion ; and  it  is  but  reasonable  to  sup- 
pose, that  hundreds  and  thousands  of  medical  students 
will  thus  be  led  astray,  till  they  learn,  from  actual  prac- 
tice at  the  bedside,  this  error  of  their  teachers.  There 
are  not  a few  practitioners,  who  have  learned,  from  expe- 


200 


CONGESTIVE  FEVER— PATHOLOGY. 


rience  and  common  sense,  the  nature  and  proper  treat- 
ment of  our  autumnal  fevers;  and  who,  though  they 
admire  the  learning  and  talents  of  their  former  teachers, 
lament  the  errors  into  which  they  have  been  led,  and  in 
which  some  of  .them  still  remain.  But  after  this  short 
digression,  I will  quote  the  following  very  appropriate 
remarks,  by  Charles  E.  Lavender,  M.  D.,  of  Selma, 
Alabama : — 

“ It  sometimes  happens  that  the  patient  dies  in  the  first 
paroxysm,  without  any  febris  at  all.  At  other  times, 
there  is  a chill,  or  cold  stage,  followed  by  a state  of  com- 
parative repose,  but  little  or  no  reaction,  to  be  succeeded 
by  another  and  fatal  cold  stage.  Venous  congestion  also 
doubtless  exists  in  other  forms  of  fever.  This  congestion, 
however,  so  far  from  being  the  seat,  or  proximate  cause  of 
the  disease  in  question,  is  but  an  effect  of  the  action  of 
the  poison  upon  the  brain  and  nervous  centres.  A simi- 
lar pathological  condition  may  be  superinduced  by  con- 
cussion, or  other  injury  done  to  the  brain.  It  is  but  a 
symptom  of  congestive  fever.  And  could  we,  with  equal 
clearness,  see  the  workings  of  the  cerebro-spinal  and 
nervous  systems,  the  motions  and  uses  of  their  fluids,  the 
degree  of  their  intensity,  the  momentum  with  which  they 
circulate,  and  the  obstructions  which  they  encounter,  we 
would  then  advance  another,  and  more  satisfactory  step, 
in  the  investigation  of  this,  as  well  as  other  forms  of  dis- 
ease. These  more  obscure,  yet  vastly  more  important, 
vital  and  pathological  phenomena  have,  unfortunately, 
been  overlooked  by  many  able  pathologists,  in  their  re- 
searches on  the  liver  and  venous  congestion.  Too  much 
importance  has  doubtless  been  attached  to  the  circula- 
tion of  the  blood,  to  the  neglect  of  the  nervous  functions. 
The  symptom  has  been  elaborately  investigated,  while 
the  cause  has  received  comparatively  little  attention. 

“ A case  that  has  assumed,  and  for  some  paroxysms 


CONGESTIVE  FEVER— PATHOLOGY. 


201 


maintained,  the  character  of  remittent  or  intermittent, 
may  suddenly  put  on  a congestive  type.  An  attack, 
which  at  first  assumed  a congestive  form,  may,  after  a 
successful  effort  at  reaction,  wear  the  face  of  remittent  or 
intermittent,  of  a mild  character. 

“ Many  cases,  in  their  onset  and  progress,  wear  the 
livery  of  all  three  of  these  types ; and  might,  at  different 
stages,  be  set  down  under  each  of  these  heads.  And. 
sometimes,  it  would  be  no  easy  matter  to  decide  upon  the 
class  to  which  a case  properly  belongs. 

“ There  is  scarcely  an  important  organ  which  may  not, 
during  the  progress  of  the  disease,  become  the  seat  of 
local  congestion.  The  spleen  may  become  engorged  to 
such  an  extent,  in  a few  hours,  as  to  be  found  double  its 
natural  size.  The  same,  to  a less  extent,  may  be  said  of 
the  liver.  Congestion  of  the  lungs  is  an  alarming  occur- 
rence,  which,  doubtless,  always  exists,  to  a greater  or  less 
extent,  in  this  form  of  fever.  The  great  oppression,  la- 
borious breathing,  heaving  of  the  chest,  and  sense  of  suf- 
focation and  sinking  down,  denote  such  a state  * * * 

“ Unfortunately  for  young  practitioners  at  the  South, 
their  knowledge  of  this  formidable  disease  is  chiefly 
drawn  from  the  well-studied  lectures  of  professors  who 
never  met  with  it  in  practice,  or  from  the  ponderous  vo- 
lumes of  writers  on  general  therapeutics,  to  whom  con- 
gestive fever  is  a matter  of  history.  The  most  unwel- 
come, and  perhaps  the  most  useful  lesson  that  such  a 
practitioner  ever  learns,  is  taught  him  by  the  first  well- 
marked  cases  of  this  type  with  which  he  meets.” 

It  is  said,  that  blood  drawn  from  a patient  who  has 
congestive  fever  is  much  darker  and  thicker  than  natu- 
ral. Charles  Frick,  M.  D.,  of  Baltimore,  gives  us  the 
result  of  the  chemical  analyses  of  the  blood  of  two  cases, 
one  of  which  he  terms  the  remittent  congestive  form 
14 


202 


CONGESTIVE  FEVER— DURATION. 


(see  No.  1 ) ; and  the  other,  the  intermittent  congestive 
form  (see  No.  7).  (See  pages  65  and  66,  and  table;  or,  the 
American  Journal  of  the  Medical  Sciences,  January  No., 
1848;  pp.  29,  30.) 

The  writer’s  observations  corroborate  the  following  re- 
marks  of  Dr.  R.  S.  Holmes : “ One  circumstance  has 
often  attracted  my  attention,  in  cases  of  diseases  from 
miasmatic  origin  in  this  country ; that  is,  the  abnormal 
actions  of  the  heart;  its  beats,  if  the  patient  has  been 
weakened  by  disease,  are  so  tumultuous  and  diversified, 
but  afford  withal  so  little  sign  of  organic  lesion,  that,  if 
not  acquainted  with  the  former  condition,  your  prognosis 
will  be  most  unfavorable.  I have  seen,  however,  but 
few  permanently  bad  results  from  this  cause.  If  you 
strengthen  the  patient  by  tonics,  and  remove  him  to  a 
more  healthy  spot,  even  in  Florida,  he  will  recover.  I 
look  upon  this  as  a deranged,  miasmatic,  nervous  action 
in  that  organ,  for  which  change  of  place  and  tonics  afford 
the  best  cure.”  According  to  my  experience,  these  ner- 
vous palpitations  or  abnormal  actions  of  the  heart  are 
most  apt  to  be  troublesome  at  night,  just  after  the  indi- 
vidual has  gone  to  bed.  Disturbances  in  the  actions  of 
the  heart  may  also  be  brought  about  by  violent  and  sud- 
den exertions. 

The  duration  of  congestive  fever  is  very  various.  In 
some  cases,  if  the  proper  treatment  be  early  resorted  to, 
the  paroxysm  may  last  only  a few  hours,  and  the  patient 
may  get  up  and  walk  about,  feeling  almost  well,  though 
somewhat  enfeebled,  and  dull.  In  more  severe  cases, 
it  may  last  several  days;  and  in  others,  especially 
those  which  are  of  the  remitterft  form,  and  in  which 
the  sensibility  of  the  nervous  system  is  greatly  im- 
paired or  benumbed ; characterized  by  languor,  dull- 


CONGESTIVE  FEVER— PROGNOSIS. 


203 


ness,  little  or  no  restlessness,  or  pain,  it  may  last  ten 
or  fifteen  days,  or  even  longer.  Nearly  all  cases  which 
last  over  three  days,  are  of  the  remittent  congestive  form. 
If  congestive  fever  does  not  result  fatally  in  two  or  three 
days  from  its  inception,  it  is  apt  to  terminate  in  conva- 
lescence, intermittent,  or  remittent  fever. 

Prognosis. — Though  congestive  fever  is  a malignant 
and  fatal  form  of  disease,  when  neglected,  or  improperly 
treated,  yet,  under  timely  and  proper  treatment,  the 
prognosis  is  nearly  always  favorable.  Thus  far,  I 
have  been  successful  in  every  case  that  has  come  un- 
der my  professional  care.  In  conversations  with  prac- 
titioners, I learn,  as  the  result  of  their  experience,  that 
death  is  extremely  rare,  as  the  result  of  congestive  fever, 
except  in  those  cases  which  have  been  neglected  too 
long,  or  have  been  improperly  treated.  Dr.  R.  S.  Holmes 
remarks,  that  he  has  “ known,  in  Chester  county,  Penn- 
sylvania, in  a small  district,  one-fourth  the  number  of 
patients  die,  who  were  seized  with  a pure  miasmatic, 
congestive  fever,  differing  from  that  of  Florida  only  in 
its  lighter  grade;  yet  the  disease,  as  treated  by  army 
surgeons  in  Florida,  with  quinine,  was  one  of  the  least 
mortal,  probably  not  more  than  one  in  forty  cases  proving 
fatal.”  Then,  after  stating  that  he  has  not  seen  a patient 
die,  who  survived  after  twenty-four  hours  from  the  time 
of  attack,  remarks,  that  “ The  fatal  cases  are  those,  in 
which  the  quinine  has  not  been  given  in  a proper  quan- 
tity, or  where  it  has  not  been  thrown  into  the  constitution 
for  a sufficient  length  of  time  to  reach  the  disease.” 

These  remarks,  will,  perhaps,  not  only  be  rather  sur- 
prising, but  probably  scarcely  credited,  by  many  who 
have  heretofore  witnessed  the  great  mortality  of  this  dis- 
ease, under  improper  treatment;  indeed,  in  many  places, 
the  term  “congestive  fever”  has  had  an  appalling  signi- 


204 


CONGESTIVE  FEVER— PROGNOSIS. 


fication,  almost  synonymous  with  death.  Coupled,  or 
followed  by  some  sensible  remarks,  I wTas  very  much 
surprised  to  see  so  frightful  an  estimate  of  the  mortality 
of  congestive  fever,  in  a southern  Medical  Journal,  wffiich 
fell  into  my  hands  some  time  last  year  (1848),  made  by 
Stephen  N.  Harris,  M.  D.,  of  Savannah,  Georgia;  and 
which  tempted  me  to  imagine  that  the  physicians  in  that 
region  of  country  have  not  yet  learned  howT  to  treat  it 
properly;  that  they  are,  perhaps,  still  under  the  erroneous 
teachings  of  Dr.  Dickson,  with  regard  to  the  too  liberal 
and  improper  use  of  calomel.  The  following  is  the  sub- 
stance of  his  remarks.  As  they  are  not  before  me,  I will 
not  vouch  that  they  are  verbatim.  “The  prognosis,  as 
might  be  anticipated,  is  exceedingly  unfavorable  in  most 
cases,  and  uncertain  in  all.  I am'unable  to  give  an  exact 
proportion  of  recoveries,  but  the  probable  ratio  is  two  in 
five  (!  !<■).  Much  depends  upon  the  youth  and  previous 
vigor  of  the  subject,  as  well  as  upon  the  concentrativeness 
of  the  congestion ; but  I am  inclined  to  think  that  much 
more  depends  upon  the  complexion  of  the  diseases  preva- 
lent at  the  time ; if  these  have  a tendency  to  typhus  or 
ataxia,  there  is  probably  a diminution  of  chances  for  in- 
ducing reaction,  and  the  disease  proceeds  to  a fatal  termi- 
nation ; but  if,  on  the  other  hand,  the  character  of  the 
season  disposes  to  activity  of  the  vital  manifestations,  the 
chances  of  recovery  are  increased.  There  is  another 
influence,  and  a most  important  one,  affecting  the  com- 
plexion of  all  diseases,  in  a greater  or  less  degree,  but 
especially  the  class  under  consideration ; it  is  the  influ- 
ence of  locality.” 

In  those  cases  which  observe  the  intermittent  type,  the 
chill  may  only  last  a few  hours,  and,  if  property  treated, 
rapid  convalescence  is  most  likely  to  ensue ; or,  if  the 
treatment  should  not  be  entirety  efficient,  a second  chill 
rnay  come  on  in  a day  or  two,  which  will  probably  be 


CONGESTIVE  FEVER— TREATMENT. 


205 


much  lighter  than  the  previous  one,  and  the  patientsoon 
recover,  under  a tonic  treatment ; but  if  the  proper  treat- 
ment be  neglected,  if  he  escape  death  in  the  first  pa- 
roxysm, a second  or  a third  may  be  more  severe,  under 
which  the  individual  may  succumb.  Those  cases  in 
which  the  paroxysm  lasts  for  a long  time — from  eight  to 
twelve  or  twenty-four  hours,  or  longer,  or  those  which 
partake  of  the  remittent  form,  are  to  be  dreaded,  and 
imperatively  demand  prompt  and  assiduous  attention. 
Cases  of  this  kind  are  more  likely  than  others  to  be 
protracted,  or  run  into  the  remittent  form  of  fever. 

E.  F.  Bouchelle,  M.D.,  of  Columbus,  Mississippi, 
says : so  long  as  he  “ pursued  the  plan  of  correcting  the 
secretions , and  stimulating  by  brandy , camphor,  camphor 
and  quinine , ammonia,  pepper,  &c.  &c.,  I lost  pa- 
tients. But  when,  on  the  other  hand,  after  much  reflec- 
tion, I had  changed  my  pathology  of  the  disease,  and 
adopted  the  cold  ivater  and  anodyne  practice,*  my  labors 
were  crowned  with  success,  and  have  been  ever  since. 
In  truth,  the  most  violent  forms  of  congestive  fever  will 
as  certainty  yield  to  the  anodyne  treatment,  as  will  a 
local  inflammation  yield  under  depletion.”  Dr.  Bouchelle 
considers  “ that  all  of  the  leading  phenomena  of  the  dis- 
ease are  referable  to  derangement  of  the  organic  system 
of  nerves  more  particularly ; the  excitement  of  conges- 
tive fever  is  irritable  excitement,  and  in  most  cases  so 
excessive  that  it  soon  sinks  the  system  into  collapse,  un- 
less moderated.” 

Treatment. — The  prompt  relief,  which  we  are  almost 
always  enabled  to  give  to  those  who  are  suffering  with 
all  the  agonies  and  distress  of  a congestive  chill,  which 


* By  the  “ cold  water  and  anodyne  practice,”  Dr.  Bouchelle  means  the 
cold  dash  to  the  general  surface,  and  opiates  internally. 


206 


CONGESTIVE  FEVER— TREATMENT. 


seem  so  ominous  of  ill,  is  enough  to  excite  within  us 
feelings  of  gratitude  to  the  Author  of  our  Being,  that  he 
has  placed  such  potent  and  effectual  means  within  our 
power,  that  he  has  given  us  minds  capable  of  appreciat- 
ing their  virtues,  and  that  we  are  therefore  instrumental, 
not  only  in  relieving  the  sufferings  of  our  fellow-beings, 
but  snatching  them,  as  it  were,  from  an  untimely  or  pre- 
mature grave,  by  neutralizing  or  rendering  ineffectual 
one  of  the  powerful  instruments  of  death.  It  is  pleasant 
to  reflect,  that  notwithstanding  the  severity  and  danger 
of  congestive  fever,  it  is  one  of  the  most  corrigible 
diseases  in  the  whole  catalogue  of  nosology,  if  it  receives 
timely  and  proper  attention.  The  treatment,  though 
plain,  and  easy  of  comprehension,  may  be  regarded  as 
one  of  the  trophies  of  the  present  day  in  the  healing  art. 

The  different  forms  or  modifications  of  congestive 
fever  require,  as  one  would  naturally  suppose,  some 
modifications  of  treatment,  so  as  to  adapt  it  to  these 
respectively.  The  two  great  and  principal  remedies  are 
quinine  and  opium ; with  the  exhibition  of  sulphuric 
ether  in  some  cases,  and  in  some  the  cold  dash  to  the 
general  surface,  &c.  &c.  If  called  to  one  of  those  vio- 
lent attacks  in  which  there  are  great  distress  and  restless- 
ness, and  the  vital  manifestations  seem  to  be  rapidly 
yielding,  as  though  the  vital  spark  would  soon  be 
smothered  out,  give,  immediately,  from  8 to  20  grains  of 
quinine,  from  50  to  100  drops  of  laudanum,  and  one  or 
two  teaspoonfuls  of  sulphuric  ether.  First,  mix  the 
laudanum  and  quinine  together,  and  give  them;  then, 
after  waiting  a few  minutes,  mix  the  ether  in  half  a glass 
of  sweetened  water,  stir  briskly  for  a moment,  and  let 
the  patient  swallow  it  down  quickly.  If  the  patient  is 
shivering,  and  manifests  much  anxiety,  a few  teaspoonfuls 
of  ether  poured  upon  a handkerchief,  and  held  to  the 
mouth  and  nose,  so  that  he  may  inhale  it,  usually  gives 


CONGESTIVE  FEVER— TREATMENT. 


207 


relief  in  a very  short  time.  These  means  will  almost 
invariably  give  speedy  relief,  especially  if  resorted  to 
soon  after  the  attack.  If  the  above  articles  should  be 
puked  up,  on  account  of  the  irritability  of  the  stomach, 
they  should  be  repeated.  If  they  should  be  thrown  up 
a second  time,  quinine  and  laudanum,  in  double  doses, 
should  be  mixed  with  an  ounce  or  two  of  starch  or  flour 
gruel,  and  given  by  injection  into  the  rectum  ; or  quinine 
and  morphine  may  be  applied  to  a blistered  surface,  first 
mixing  them  with  a little  thin  paste,  or  gruel,  made  of 
flour  or  starch;  twenty  or  thirty  grains  of  quinine,  with 
one  grain  of  sulphate  of  morphine,  will  be  a sufficient 
amount  for  this  purpose.  The  blister  should  be  prefera- 
bly made  on  the  nape  of  the  neck,  between  the  shoulders, 
or  over  the  region  of  the  stomach.  In  order  to  make 
a blister  quick,  so  as  not  to  lose  important  time,  it 
may  be  done  almost  immediately,  by  dipping  a piece  of 
cloth  in  concentrated  acetic  acid,  solution  of  ammonia, 
&c.,  or  the  application  of  hot  water.  In  such  cases  as 
the  one  above  instanced,  some  practitioners  speak  very 
highly  of  the  cold  dash.  If  the  stomach  should  have 
retained  the  remedies  (rendering  it  unnecessary  to  give 
them  by  injection,  or  their  application  to  a blistered  sur- 
face), it  may  be  necessary  to  repeat  the  laudanum  and 
ether,  though  in  smaller  quantities,  say  from  30  to  50 
drops  of  each ; if  the  former  is  slow  in  producing  any 
effect,  in  the  course  of  half  an  hour,  or  an  hour  or  two, 
according  to  the  severity  of  the  case,  and  the  distress  and 
anxiety  of  the  patient.  I commonly  repeat  the  dose  of 
quinine  in  three  or  four  hours.  This  plan  of  treatment 
is  almost  sure  soon  to  give  relief  and  repose,  bring  about 
moderate  reaction,  and  a rapid  convalescence.  The  pa- 
tient should,  however,  to  insure  recovery,  and  prevent 
relapse,  take  from  three  to  five  grain  doses  of  quinine 
four  or  five  times  a day ; and,  if  dysentery  attend,  in  ad- 


208 


CONGESTIVE  FEVER— TREATMENT. 


dition  to  the  quinine,  from  25  to  40  or  50  drops  of  lauda- 
num, or  one  or  two  teaspoonfuls  of  paregoric,  should  be 
given  once,  twice,  or  thrice  a day,  or  as  occasion  requires ; 
to  which  may  sometimes  be  added  with  advantage,  if  it 
prove  obstinate,  some  astringent,  as  krameria,  catechu, 
tannin,  a strong  decoction  of  oak  bark,  if  the  stomach  will 
bear  it,  tincture  of  cinnamon,  or  sugar  of  lead,  which 
latter  may  be  given  with  the  opiates,  but  should  not  be 
given  with  the  quinine,  or  for  an  hour  or  two  after  a dose 
of  quinine  has  been  taken,  as  these  two  articles  are  in- 
compatible with  each  other. 

In  those  cases  attended  with  great  restlessness  and  op- 
pression, the  patient  tossing  to  and  fro  in  bed,  the  extre- 
mities and  general  surface  of  an  icy  coldness,  with 
exceptions,  in  some  cases,  of  the  region  about  the  chest 
and  head,  which  may  be  of  a natural  or  morbid  heat; 
and  more  particularly,  also,  if  the  general  surface  is  not 
covered  with  perspiration,  in  addition  to  the  use  of  qui- 
nine and  laudanum,  some  practitioners  have  great  confi- 
dence in  the  cold  clash,  to  bring  about  reaction  and 
composure : indeed,  I believe  a few  practitioners  rely 
almost  exclusively  on  the  cold  dash  to  bring  about  reac- 
tion. The  patient,  stripped  of  his  clothing,  is  laid  on  a 
blanket  on  the  floor,  several  buckets  of  cold  water  are 
then  dashed  all  over  him  ; he  is  then  wiped  dry,  perhaps 
some  hasty  friction  is  used  ; he  is  then  put  in  bed,  and 
covered  with  two  or  three  blankets,  to  assist  in  bringing 
about  reaction.  However  useful  the  cold  dash  may  be, 
we  should  not  rely  on  it,  to  the  exclusion  of  quinine  and 
laudanum,  and  ether,  if  necessary.  As  before  remarked, 
some  practitioners  have  great  confidence  in  the  cold  dash, 
but  I may  observe  that  there  are  others  who  do  not  seem 
to  think  favorably  of  it.  It  would  seem  from  this,  that 
we  might  infer  that  there  are  some  cases  to  which  it  is 
adapted,  and  some  to  which  it  is  not.  So  far  as  I am 


CONGESTIVE  FEVER— TREATMENT. 


209 


aware,  the  cases  to  which  it  is  applicable  are  not  yet  well 
settled.  I have  taken  some  pains  to  try  to  acquire  infor- 
mation on  this  subject,  and  it  appears  that  it  is  most 
adapted  to  such  cases  as  the  last  one  instanced  above ; 
and  that  in  the  following  conditions  it  is  not  applicable, 
or  does  little  or  no  good — as  in  those  cases  which  come 
on  slowly  and  insidiously,  torpidity  of  the  system  and 
dullness ; no  restlessness,  but  great  prostration  ; weak 
pulse,  cold  extremities,  etc.  I might  refer  to  the  expe- 
rience of  reputable  practitioners  to  prove  the  potency  of 
the  cold  dash  in  the  treatment  of  congestive  fever.  We 
have  already  incidentally  referred  to  the  confidence  Dr. 
Bouchelle,  of  Columbus,  Miss.,  reposes  in  it.  So  far  as  I 
have  been  able  to  learn,  our  own  countryman,  Dr.  Thomas 
Fearn,  of  Huntsville,  Alabama,  was  the  first  to  resort  to 
the  cold  dash  in  congestive  fever.  Dr.  Fearn  was  also 
the  first  who  used  quinine  in  large  doses;  which  he  did  but 
a few  years  after  this  article  was  discovered  by  Pelletier 
and  Caventeau,  in  1820.  The  success  attending  its  exhi- 
bition in  what  once  would  have  been  regarded  as  very 
large  doses,  and  even  yet  at  the  North,  might  have  rea- 
sonably induced  one  to  fear  that  it  would  be  injudiciously 
used  by  many,  and  thus  be  productive  of  mischief ; and 
such  has  been  the  case.  Considering,  however,  its  po- 
tency for  good,  its  evil  effects  are  comparatively  small. 
Dr.  Perrine,  of  Mississippi,  was  one  of  the  next  after  Dr. 
Fearn,  to  appreciate  the  value  of  quinine  in  larger  doses 
than  had  formerly  been  used. 

Dr.  R.  S.  Holmes  says,  “It  cannot  be  thought  strange 
that  the  practice  at  the  North  of  giving  quinine  in  divided 
doses  for  bilious,  remittent,  and  congestive  fevers,  should 
prove  so  unsuccessful.  Though  the  fevers  there  do  not 
require  such  large  doses  of  this  article  as  at  the  South, 
they  require  very  different  ones  from  those  that  are  now 


given. 


210 


CONGESTIVE  FEVER— TREATMENT. 


“ The  experience  of  physicians  in  the  south  of  France, 
in  Italy,  and  in  the  southern  States  of  the  Union,  shows 
that  a much  larger  dose  of  quinine  is  necessary  to  check 
a fever  in  those  countries,  than  in  latitudes  and  regions 
where  malarious  influence  is  not  so  powerful. 

“ On  my  arrival  in  Florida,  knowing  nothing  of  south- 
ern diseases  from  practice,  and  being  stationed  alone  at  a 
distant  and  unhealthy  post,  I learned  the  rules  by  expe- 
rience alone,  guided  by  which  I have  since  successfully 
administered  quinine.  I practiced  on  northern  precepts, 
annoying  the  patient  without  arresting  the  disease,  by  a 
continued  succession  of  two  grain  pills ; occasionally,  at 
long  intervals,  checking  the  disease  by  these  means,  but 
much  more  frequently  vexed  for  weeks  by  the  continued 
sickness  of  the  soldier.-*  I rose  finally  to  ten  grains,  and 
continued  to  give  this  quantity  at  once.  I more  fre- 
quently succeed  by  this  practice,  but  not  yet  to  my  satis- 
faction. * * Finally,  convinced  that  large  doses  of 
quinine  are  necessary  in  the  South,  I increased  my 
minimum  dose,  for  intermittent  fever,  to  fifteen  grains 
given  at  once.” 

Dr.  Holmes  was  in  the  habit  of  giving  thirty,  forty,  or 
more  grains  of  quinine  at  once,  in  congestive  fever. 
He  says  the  largest  amount  of  quinine  he  has  ever 
given  at  a single  dose,  has  been  eighty  grains ; this  is 
the  extreme  dose;  the  average  quantity  is  about  twenty 
grains.  Quinine  has  even  been  given  in  larger  doses 
than  this ; but  I do  not  approve  of  this  practice,  as  I 
consider  these  doses  unnecessarily  large,  and  they 
sometimes  produce  bad  effects.  The  late  Judge  "Willis, 
of  Mississippi,  informed  me,  some  years  ago,  that  he 
knew  a case  or  two  of  insanity  produced  by  excessively 

* See  Amcr.  Journ.  Med.  Sci.,  Oct.  1846.  Does  not  this  show  the  folly  of 
sending  northern  physicians  with  our  soldiers  to  the  South? 


CONGESTIVE  FEVER— TREATMENT. 


211 


large  doses  of  quinine.  Moreover,  I believe  that  ten,  fif- 
teen, or  twenty  grain  doses,  with  a dose  of  laudanum,  will 
have  a better  effect,  and  consequently  do  more  good,  than 
thirty  or  eighty  grains  of  the  quinine  given  alone.  In  ad- 
dition to  this,  if  the  patient  is  thirsty,  he  should  he 
allowed  moderate  quantities  of  cold  or  iced  water,  fre- 
quently repeated. 

In  cases  attended  with  coma  or  lethargy , and  in  which 
deglutition  cannot  be  performed,  the  quinine  and  lauda- 
num should  be  given  in  double  doses  by  injection,  or  a 
double  dose  of  quinine  (twenty-five  or  thirty  grains), 
and  one  grain  of  sulphate  of  morphine  may  be  applied 
to  a blistered  surface,  as  before  directed.  Dry  frictions 
to  the  extremities,  and  along  the  spinal  column,  or  with 
pepper,  mustard,  or  spirits  of  turpentine,  maybe  of  some 
service  as  adjuvantia ; as  also  heat,  applied  to  them  by 
means  of  hot  rocks,  bricks-,  bottles  filled  with  hot  water,  or, 
if  the  skin  is  dry,  a dozen  ears  of  corn,  just  taken  out  of 
hot  water,  is  preferable.  If  costiveness  attends  cases  of 
this  kind,  ten  grains  of  calomel  and  fifteen  grains  of 
rhubarb  should  be  given  with  the  quinine  and  laudanum 
at  the  commencement  of  the  treatment,  or  as  soon  as 
deglutition  can  be  performed.  It  may  be  necessary  to 
repeat  the  calomel  and  rhubarb  once  or  twice,  with  in- 
tervals of  twenty-four  or  forty-eight  hours.  If  nothing 
can  be  given  by  the  mouth,  resort  to  injections  of  spirit 
of  turpentine  and  castor  oil,  in  order  to  relieve  the  cos- 
tiveness, when  necessary.  These  remarks  will  apply  to 
all  cases  of  this  disease  attended  with  costiveness. 

Some  cases  are  attended  with  languor,  dullness,  tor- 
pidity, and  costiveness,  and  require  the  same  treat- 
ment as  just  given  above,  with  the  exception  that  in 
these  cases  the  medicines  can  be  given  by  the  mouth. 

Some  cases  are  attended  with  great  restlessness,  op- 
pression, rolling  to  and  fro  in  the  led , &c.,  and  very  ob- 


212 


CONGESTIVE  FEVER— TREATMENT. 


stinate  costiveness,  and  require  the  same  treatment.  If 
the  skin  is  dry,  the  cold  dash  may  here  also  be  of 
service. 

In  some  of  these  cases,  the  bowels  appear  to  be  almost 
insensible  to  the  influence  of  cathartics,  and,  therefore, 
it  will  be  necessary  to  give  some  of  the  more  active  ones ; 
as  spirits  of  turpentine  and  castor  oil — and  these  may  be 
also  given  by  injection.  If  the  patient  cannot  swallow 
anything,  a drop  of  croton  oil  may  be  applied  to  the 
tongue.  We  should  guard  against  too  active  and  violent 
catharsis,  though  under  these  circumstances  it  is  not 
likely  to  occur.  Purging,  as  a general  rule  in  this 
malady,  should  be  avoided. 

If  the  disease  is  disposed  to  assume  the  remittent  form, 
with  cotemporary  costiveness,  the  calomel  and  rhubarb, 
as  above  directed,  should  be  given  every  twenty-four, 
thirty-six,  or  forty-eight  hours,  till  two  or  three  doses  have 
been  exhibited.  If  the  bowels  do  not  respond  to  the  ape- 
rient influence  of  these  articles,  some  other  should  be 
<nven,  so  as  to  determine  this  effect.  Extract  of  white 
walnut  and  dandelion  is  well  suited  for  this  purpose. 
The  calomel  is  not  solely  given  for  its  aperient  effect  ; in 
conjunction  with  the  other  remedies  it  has  a tendency  to 
relieve  local  congestions,  which  are  connected  with  a sort 
of  subacute  inflammation,  especially  of  the  brain,  as  well 
as  the  viscera  of  the  thorax  and  abdomen ; and,  with 
them,  has  also  a favorable  influence  on  the  secre- 
tions. It  should  never  be  given  to  the  extent  of  pro- 
ducing salivation.  In  the  costive  cases  above  noticed, 
the  quinine  appears  to  coincide  with  cathartics  in  making 
the  bowels  more  susceptible  of  their  influence.  If  at 
any  time  the  cathartics  should  operate  too  much,  or  too 
freely  ; or,  if  irritation  of  the  bowels,  with  too  frequent 
discharges  from  them  should  be  produced;  or  if  this 
condition  should  come  on  spontaneously,  as  the  re- 


CONGESTIVE  FEVER— TREATMENT. 


213 


suit  of  morbid  action,  it  should  be  controlled  by  lauda- 
num, opium,  or  morphine;  and,  if  very  obstinate,  some  of 
the  astringents  mentioned  above  may  be  associated  with 
the  laudanum. 

In  any  of  the  above-mentioned  forms  of  congestive 
fever,  the  quinine  should  be  repeated  in  full  doses  every 
three  or  four  hours,  as  long  as  the  paroxysm  lasts ; after 
which  it  should  be  given  in  doses  of  from  four  to  six  or 
eight  grains,  from  three,  to  four  or  five  times  a day,  to 
insure  recovery,  and  prevent  the  coming  on  of  another 
paroxysm.  If  the  quinine  produces  roaring  in  the  head, 
or  buzzing  in  the  ears,  this  should  teach  us  that  it  has 
had  a good  effect,  is  overcoming  the  morbid  condition  of 
the  system; — after  which,  the  too  liberal  and  indiscrimi- 
nate use  of  this  article  would  be  likely  to  prove  injurious ; 
therefore,  -when  these  effects  on  the  brain  are  manifest, 
the  quinine  should  be  given  in  smaller  doses,  and  after 
longer  intervals. 

As  the  system  begins  to  rally,  and  reaction  slowly  de- 
velopes  itself,  the  body,  or  general  surface,  becomes 
warmer,  and  the  warmth  gradually  extends  to  the  extre- 
mities ; the  veins  which  are  near  the  surface  begin  to 
look  more  full  and  prominent ; the  features  and  general 
surface,  from  being  contracted  and  pale,  become  full, 
more  expanded,  and  of  a more  florid  hue,  and  the  dis- 
tress and  anxiety  of  the  patient  are  greatly  relieved,  un- 
less there  should  be  too  much  determination  to  some 
important  organ,  especially  the  brain ; which,  however, 
is  rarely  the  case,  unless  such  stimulants  as  brandy,  wine, 
etc.,  have  been  improperly  or  too  freely  given.  If  this 
should  be  the  case,  or  the  reaction  too  great,  it  may  be 
controlled  by  frequently  and  freely  pouring  cold  water 
over  the  head  and  back  of  the  neck,  and  indeed  over  the 
whole  body;  or,  if  less  so,  sponging  the  whole  person, 
if  the  skin  is  hot  and  dry,  and  the  exhibition  of  from 


214 


CONGESTIVE  FEVER— TREATMENT. 


eight  to  twelve  or  fifteen  grain  doses  of  quinine,  and 
one-third  to  a half  grain  of  sulphate  of  morphine.  If 
the  stomach  is  not  irritable,  the  addition  of  two  grains 
of  ipecac.,  or  one  teaspoonful  of  the  tincture  of  lobelia 
may  be  proper.  If  the  reaction  or  affection  of  the  brain 
should  persist,  these  should  be  repeated  every  four  or  five 
hours,  suspending  the  morphine  when  the  system  has  been 
brought  under  its  influence  ; nor  should  the  cold  water, 
as  above  recommended,  be  sparingly  used.  The  reac- 
tion, however,  in  congestive  fever,  is  seldom  very  great, 
and  is  usually  easily  controlled. 

If  the  fever  runs  into  remittent  or  intermittent,  the  treat- 
ment adapted  to  these  respectively  is  proper ; being  care- 
ful not  to  adopt  a too  antiphlogistic  course,  always 
avoiding  general  blood-letting,  unless  circumstances  oc- 
cur which  most  unequivocally  demand  a resort  to  it,  and 
then  it  should  be  practiced  with  caution. 

My  object  is  to  be  brief  and  practical,  therefore  it 
it  is  not  my  present  purpose  to  undertake  to  refute  the 
false  theories  and  modes  of  practice  which  have  been 
published.  Some  ingenious  medical  writers  who  have 
embraced  erroneous  views,  and  whose  learning  and  ta- 
lents enable  them,  with  their  captivating  style  and  sophis- 
try, to  render  their  opinions  plausible,  indeed  I should  say, 
to  enforce  conviction  in  relation  to  their  theories,  have  un- 
fortunately led  not  a few  astray.  Venesection , recommend- 
ed by  Armstrong  and  others,  was  found  to  be  improper 
some  twenty  years  ago,  by  Dr.  Beatty,  of  Maryland, 
which  fact  he  made  known  to  the  public  in  the  Tran- 
sjloania  Journal,  in  1829.  Still,  with  the  history  of  the 
past  before  them,  there  are  some  who  are  yet  misguided 
on  this  subject,  who  now  occasionally  resort  to  bleeding 
in  congestive  fever,  but  without  doing  any  good  (unless 
it  exist  in  their  imaginations,  so  as  to  force  practice 


CONGESTIVE  FEVER— TREATMENT,  BLOOD-LETTING  IN.  215 


to  correspond  with  their  false  theories),  to  say  nothing 
of  the  collapse  and  danger,  perhaps,  I should  say,  the 
fatality  of  this  practice.  When  general  blood-letting  can 
be  of  any  service,  or  when  it  is  justifiable  to  resort  to  it, 
it  appears  to  me  that  the  two  following  cases,  published 
by  Dr.  Lavender,  point  out  the  circumstances  under 
which  it  may  be  of  advantage,  and  the  manner  in  which 
it  should  be  practiced. 

“ H.  S..  aged  eighteen,  after  a day  or  two  of  the  usual 
premonitories,  at  ten  A.  M.,  Sept.  10th,  1941,  became 
cold,  restless,  oppressed,  with  occasional  rigors;  could 
not  be  confined  to  his  room ; lay  a few  minutes  in  one 
bed,  and  then  hurried  to  another.  Extremities  cold  to 
the  body,  but  some  morbid  heat  about  the  head  and  chest. 
Was  put  into  the  warm  bath,*  fainted,  and  was,  with  some 
difficulty,  restored.  Saw  him  at  six  P.  M. ; pulse  barely 
perceptible  at  the  wrist,  one  hundred  and  fifty,  deep- 
seated,  thready,  and  intermitting;  skin  very  cold,  but 
much  complaint  of  heat,  and  sense  of  suffocation;  fre- 
quent sighing,  and  interrupted  respiration ; remains  but 
a minute  in  one  position,  and  will  not  be  covered ; some 
watery  purging ; countenance  pale,  shrivelled,  and  anx- 
ious; eyes  suffused  and  watery;  intellect  good.  Ordered 
immediately  brandy,  camphor,  and  laudanum,  with  fric- 
tions of  dry  mustard.  Was  preparing  sinapisms,  when 
the  attendants  cried  out  ‘ he  is  dead  !’  On  approaching 
the  bed,  found  him  motionless  and  pulseless;  breathing 
had  ceased,  and  no  motion  could  be  felt  over  the  region 
of  the  heart;  jugulars  much  distended,  With  the  case, 

* From  the  instructions  heretofore  given,  the  reader  is  prepared  to  judge 
of  the  impropriety  and  danger  of  the  resort  to  the  warm  bath  in  such  cases 
as  this.  The  cold  dash  would,  no  doubt,  have  been  of  much  more  service  ; 
and  quinine,  ether,  and  laudanum  would  have  been  preferable  to  the  brandy, 
camphor,  and  laudanum  ; though  these  latter  may  be  resorted  to  when  the 
others  are  not  at  hand. 


216  CONGESTIVE  FEVER— TREATMENT,  BLOOD-LETTING  IN. 

of  the  day  before,  fresh  in  my  mind,  I instantly  opened 
a jugular  vein,  which  bled  freely.  In  about  one  minute 
after,  the  blood  began  to  flow,  the  patient  breathed,  and 
the  pulsations  of  the  heart  were  again  manifest.  Sina- 
pisms, lotions,  frictions.  Brandy  and  water,  almost 
thickened  with  quinine  and  camphor,  thrown  into  the 
stomach.  In  ten  minutes  he  breathed  freely,  and  swal- 
lowed without  difficulty.  In  twenty  minutes,  he  spoke 
rationally,  and  took  readily  whatever  Avas  offered  him  ; 
pulse  could  be  counted  at  the  wrist,  one  hundred  and 
fifty.  For  some  hours  he  rested  well,  and  hopes  were 
entertained  of  successful  reaction.  He  sunk  eight  hours 
after  the  bleeding.” 

Second  case,  alluded  to  above : “ Sancho,  a colored 
man,  aged  thirty-five,  taken  on  the  4th  of  September, 
1842,  without  any  premonitory  symptoms,  and  soon  sunk 
into  collapse.  Saw  him  at  ten  P.  M.,  eight  hours  after 
access.  Insensible;  low,  muttering  delirium,  and  rolling 
on  the  floor,  but  now  quiet;  eyes  fixed;  pulse  a mere 
flutter;  breathing  laborious  and  rattling;  supposed  to  be 
dying. 

“ The  brain  appeared  to  be  the  seat  of  congestion,  he 
having  been  insensible  from  the  access;  opened  a tem- 
poral artery  ; bled  imperfectly  ; opened  a jugular ; bled 
freely,  at  intervals,  for  an  hour  or  two,  with  marked  im- 
provement of  symptoms  ; about  twenty  fluidounces  ; rub- 
bed all  over  with  spirits  capsicum  and  mustard ; cold  dash 
to  head,  sinapisms  to  feet;  stim.  enemata;  spirits  quin., 
camph.  liberally.  In  the  course  of  twelve  hours,  one 
drachm  calomel  had  established  free  secretion  from  the 
liver  and  bowels;  reaction  took  place;  a common  remit- 
tent followed,  which  yielded  to  ordinary  remedies/' 

Dr.  Lavender  then  makes  the  following  judicious  re- 
marks on  the  use  of  blood-letting  in  this  disease  : — 


CONGESTIVE  FEVER— TREATMENT,  BLOOD-LETTING  IN.  217 


“ Although  a few  cases  like  the  above  have  induced 
me  favorably  to  regard  bleeding  from  the  jugular  vein, 
in  desperate  cases  of  congestive  fever,  or  in  which  con- 
gestion of  the  brain  exists,  yet  I am  compelled  to  regard 
the  use  of  the  lancet,  in  this  malignant  form  of  miasmatic 
disease,  as  a most  hazardous  and  often  fatal  practice. 

“ During  the  progress  of  reaction  from  a congestive 
chill,  inflammation  of  the  stomach,  liver,  or  other  im- 
portant organ,  sometimes  makes  its  appearance,  accom- 
panied by  fever  of  high  excitement,  as  a sequela  of  the 
engorgement  of  these  organs-.  Such  cases  may  require 
topical,  and  if  the  inflammatory  symptoms  run  high, 
general  blood-letting.  But  while  the  distinctive  symp- 
toms of  congestion  remain,  while  there  are  great  restless- 
ness and  oppression,  quick,  intermitting,  or  compressible 
pulse,  laborious  breathing,  especially  if  there  is  no  con- 
gestion of  the  brain — the  lancet  should  not,  for  a moment, 
be  thought  of.  Even  where  the  symptoms  have,  in  a 
measure,  given  way,  and  reaction  been  partially  esta- 
blished; when  the  heat  becomes  equalized,  oppression  al- 
leviated, pulse  full,  and  slightly  resisting — even  then,  a 
small  bleeding  may,  and  a large  one  will,  almost  inevita- 
bly, bring  on  a rapid  and  fatal  collapse. 

V There  is  yet  another  condition  that  deserves  marked 
attention,  because  it  is  so  likely  to  betray  the  young 
practitioner  into  the  use  of  the  lancet.  It  is,  when  a 
congestive  attack  has  yielded  to  the  influence  of  quinine; 
reaction  appears  to  be  complete,  natural  temperature  is 
restored  to  the  surface,  pulse  becomes  full  and  flowing, 
with  a peculiar  swell  under  the  finger,  and  slight  sensa- 
tion of  resistance.  At  the  same  time  there  is  a feeling 
of  restlessness  and  apprehension;  dull  headache,  with 
fullness  of  superficial  veins.  The  patient  complains  of 
oppression,  and  often  requests  to  be  bled.  Open  a vein, 
and  the  blood  flows  freely,  looks  dark  and  thick.  When 
15 


218  CONGESTIVE  FEVER— TREATMENT,  BLOOD-LETTING  IN. 

eight  or  twelve  ounces  have  been  drawn,  the  bleeding 
suddenly  stops,  the  venous  fullness  has  left  the  surface, 
which  becomes  pale  and  shrunken ; the  pulse  quick  and 
thread-like ; an  indescribable  sense  of  sinking  comes 
over  the  patient ; he  cannot  be  controlled,  but  tosses  in 
bed,  or  rises  to  his  feet  and  falls.  In  a few  hours  death 
closes  the  scene.  At  other  times  you  may  bleed  freely, 
in  such  cases  as  the  above,  with  relief  to  the  head,  and 
no  perceptible  ill  effects  for  one  or  two  hours  after  the 
bleeding,  and  when  you  begin  to  congratulate  yourself 
upon  your  success,  the  patient  becomes  faint,  nausea  and 
vomiting  follow,  and  a few  hours  may  close  the  scene. 

“ In  this  latitude,  fevers  of  any  kind  do  not  bear  the 
lancet  well.  Congestive  fever  does  not  make  its  appear- 
ance till  the  system  is  greatly  weakened  by  long-con- 
tinued and  excessive  heat.  When  it  has  made  its  attack, 
the  vital  force  is  very  much  exhausted,  and  the  patient 
is  fast  falling  into  collapse.  In  such  cases  as  this,  I 
would  earnestly  say  to  my  young  professional  brethren — 
Beware  of  the  lancet!  Be  assured,  without  proving  by 
sad  experience,  that  the  lancet,  instead  of  being  ‘ the 
anchor  of  hope,’  is  emphatically  the  sickle  of  death  in 
congestive  fever. ”* 

The  observations  of  Dr.  Lavender,  in  relation  to  open- 
ing the  jugular  vein,  appear  to  correspond  with  some  ex- 
periments made  by  Dr.  J.  Reid,  on  the  lower  animals; 
who  says,  “ that  disgorging  the  right  side  of  the  heart, 
when  its  contractions  were  enfeebled  or  suspended,  by 
opening  the  jugular  vein,  had,  in  some  cases,  a decided 
effect  in  renewing  its  action;  and  the  same  may,  doubt- 
less, occur  from  bleeding  practiced  under  the  circum- 

* Those  who  wish  to  see  the  interesting  paper  from  which  the  above  ex- 
tracts are  taken,  will  find  it  in  the  Amer.  Journ.  of  Med.  Sci.,  July  No. 
1848. 


CONGESTIVE  FEVER— TREATMENT. 


219 


stances  mentioned.  It  is  important,  indeed,  to  bear  in 
mind,  that  the  congestion  of  the  cavities  of  the  heart 
speedily  arrests  the  action  of  that  viscus.”  ( Dunglison .) 

As  the  quinine,  laudanum,  and  other  means  used  for 
congestive  chill,  begin  to  manifest  their  favorable  influ- 
ence, all  the  distressing  symptoms  and  abnormal  condi- 
tions begin  to  abate;  the  frequent,  feeble,  and  irregular 
pulse,  becomes  slower  and  more  ample ; the  breathing 
becomes  more  free  and  full ; the  oppression  and  restless- 
ness gradually  abate ; the  general  surface  and  extremities 
approach  a natural  temperature,  and  become  covered 
with  a warm  perspiration,  approaching  a healthy  con- 
dition. If  the  region  about  the  chest  and  head  has  been 
in  a state  of  morbid  heat, it  becomes  cooler;  the  sensation 
of  inward  heat  is  greatly  relieved  ; the  disturbances  of 
the  brain  are  modified;  the  patient  becomes  calm,  and 
perhaps  falls  into  a comfortable  sleep.  When  these 
favorable  symptoms  occur,  with  subsequent  proper  treat- 
ment and  attention  we  may  predict,  with  almost  abso- 
lute certainty,  a favorable  issue,  a speedy  convalescence. 

After  a paroxysm  is  over,  quinine  should  be  taken  as 
heretofore  advised;  but  if  the  individual  resides  in  a 
highly  malarious  region  of  country,  there  probably 
is  some  danger  of  a recurrence  of  the  paroxysm  in  the 
next  twenty-four  hours,  or  the  second  or  third  day. 
When  this  is  to  be  feared,  the  patient  should  take  a 
large  dose  of  quinine  (ten  or  fifteen  grains)  and  lauda- 
num, about  three  hours  before  the  expected  period  of 
recurrence. 

As  quinine  is  so  important  an  article  in  the  treatment 
of  congestive  fever,  and  other  southern  diseases,  and 
as  its  too  liberal  and  injudicious  use,  on  the  one  hand, 
may  be  productive  of  injury,  while,  on  the  other,  a timid 
resort  to  it  in  small  doses  may  not  only  be  productive. of 


220 


CONGESTIVE  FEVER— TREATMENT— QUININE. 


injury  directly,  but  indirectly,  by  letting  the  patient  die, 
a brief  notice  of  the  virtues  and  influence  of  this  article 
may  here  not  be  unwelcome  to  the  reader;  especially  as, 
while  there  are  prejudices  entertained  against  it,  by  some, 
others  are  too  enthusiastic  in  its  favor;  and  no  doubt,  now 
and  then,  produce  deleterious  effects  by  its  injudicious 
use.  Dr.  R.  S.  Holmes  remarks,  that  “ It  is  the  continued 
small  doses  of  this  agent,  that  harass  and  irritate.  A pa- 
tient, at  the  Nort  h,  takes  one  or  two  grains  almost  daily, 
for  weeks,  until  he  has  swallowed  sixty  or  more  grains  in 
the  course  of  a month,  and  then  is  indignant  at  the  idea  of 
a fifty  or  sixty  grain  dose  being  given  at  once  in  Florida, 
which  suffices  for  the  same  period.”  This,  as  all  may 
readily  see,  is  bad  logic.  Suppose  an  individual  were  to 
take  as  much  strychnine  or  arsenic  at  one  dose,  as  he 
could  bear  without  injury,  in  a month.  Would  not  death 
speedily  ensue?  It  is  true,  that  quinine  may  be  used 
with  much  greater  impunity  than  these  articles.  But 
again,  suppose  that  an  individual  were  to  eat,  at  once, 
as  much  pork,  bacon,  or  beef,  or  any  other  article,  as  is 
usually  consumed  by  him  in  a month.  What  would  be 
the  result?  Dr.  Holmes  says:  “ Quinine,  as  a remedy 
for  periodicity,  is  to  be  given,  regardless  of  any  existing 
state  of  inflammation.  Never  give  quinine  in  divided 
doses,  when  directed  for  the  immediate  cure  of  a periodi- 
cal disease.  To  he  certain  of  the  operation  of  quinine  in 
a constitution  with  which  you  are  not  acquainted,  it  must 
be  given  eighteen  hours  before  the  desired  result.  In 
emergent  cases  it  may  be  given  in  the  lowest  state  of 
prostration,  or  the  highest  grade  of  the  fever.  As  a 
general  rule,  fifteen  to  twenty  grains  will  be  necessary 
for  an  intermittent,  and  thirty  to  fifty  for  a congestive 
fever.”  The  diseases  in  Florida,  no  doubt,  require  large 
doses  of  quinine;  but  I think  Dr.  Holmes  gives  it  in  un- 
necessarily large  doses,  and  too  exclusively;  as  I am 


CONGESTIVE  FEVER— TREATMENT— QUININE. 


221 


inclined  to  believe,  from  my  own  experience,  that  from 
ten  or  fifteen  to  twenty  grains,  with  a dose  of  laudanum, 
will  have  a better  effect  than  the  huge  doses  of  sixty  or 
eighty  grains  of  quinine  alone.  Dr.  H.  remarks,  “If  the 
physician  in  the  South  can  be  blamed  for  his  too  great 
enthusiasm  for  the  specific  (if  there  is  such  a thing)  for 
all  these  ills,  he  has  certainly  chosen  a hand-maiden 
worthy  of  his  worship.  To  one  accustomed  to  look  at 
the  slow  and  languid  operation  of  medicines,  in  fevers  at 
the  North,  and  the  want  of  faith  with  which  they  are  so 
often  given,  the  operation  of  this  medicine  appears  mi- 
raculous; it  is  only  equalled,  when  it  has  fair  play,  by  its 
certainty. 

“ The  immediate  effects  of  a large  dose  of  quinine  are, 
buzzing  and  murmuring  in  the  ears  ; a partial  deafness, 
which  often  continues  for  twenty-four  hours;  a great 
sense  of  fullness  about  the  head,  and  often  a dull  pain 
across  the  forehead  ; there  is  generally  more  or  less  ex- 
citement or  partial  delirium  of  the  mind,  without  exciting 
the  spirits  in  any  degree.  I have  seen  patients  under 
the  effects  of  quinine,  wander  and  talk  incoherently,  as 
if  from  the  influence  of  alcohol.  Occasionally,  it  will 
produce  a pricking  sensation  in  the  skin,  and  a quivering 
in  the  muscles  of  the  fingers  and  eyelids.  One  patient 
I knew  who  was  always  made  perfectly  insane,  and  be- 
side himself,  so  that  he  had  to  be  confined,  even  by  the 
administration  of  five  grains  of  quinine.  I have  never 
seen  any  of  these  symptoms  last  much  longer  than 
twenty-four  hours.” 

The  remarks  of  Dr.  Lavender  perfectly  express  my 
own  views  and  experience,  and  may  be  regarded  as 
an  infallible  rule  in  the  exhibition  of  quinine.  They 
are  as  follows : “ I am  by  no  means  persuaded  that  qui- 
nine is  a harmless  agent,  and  may  be  given,  in  almost 
any  quantity,  without  producing  hurtful  consequences. 


222 


CONGESTIVE  FEVER— TREATMENT— QUININE. 


When  pushed  too  far,  painful  fullness  of  the  brain,  alarm- 
ing sounds,  and  ringing  in  the  ears,  deafness,  slight  de- 
lirium, twitching  of  tendons  and  hiccough,  will  be  some 
of  the  consequences.  Caution  must,  therefore,  be  exer- 
cised, not  to  push  this  valuable  remedy  too  far.  Over- 
work the  brain,  and  the  vital  powers  may  become  exhausted 
by  too  long  continued  and  excessive  action.  In  this  way , 
1 have  no  doubt,  frequently  repeated  heroic  doses  of  qumine 
exhaust  the  vital  powers,  cause  indirect  debility,  and  thus 
hasten  that  very  collapse  which  quinine,  judiciously  ad- 
ministered, is  so  well  calculated  to  avert. 

u In  like  manner  brandy,  and  other  stimulants,  though 
valuable  in  supporting  the  vital  force,  and  preventing 
collapse,  or  in  arousing  the  system  from  that  state,  and 
for  such  purposes,  may  be  given  in  large  quantities  ; yet 
may  they  be  pushed  too  far,  or  be  continued  too  long,  and 
thereby  aid  in  producing  that  condition  which  they  were 
intended  to  prevent.  They  are  useful,  and  may  be  given 
liberally,  while  they  act  in  harmony  with  the  system, 
quiet  the  stomach,  soothe  the  brain,  and  invigorate  the 
circulation.  But  if  they  cause  pain  in  the  stomach, 
headache,  or  symptoms  of  intoxication,  they  should  be 
used  more  cautiously,  or  be  discontinued  altogether.  A 
patient  who  may  have  borne  a pint  of  brandy  in  twelve 
hours  before  reaction,  may  not  bear  an  ounce  afterwards. 
The  same  observation  is  applicable  to  quinine.  Although 
twenty  grains  of  the  sulphate  may  have  been  taken,  with 
the  most  decided  benefit,  in  a case  of  collapse,  or  in  a 
case  of  congestive  chill  threatening  collapse,  yet,  when 
reaction  has  been  established,  one  grain  may  be  sufficient, 
and  even  that  not  always  required,  and  sometimes  hurt- 
ful.” That  is,  if  the  reaction  is  a healthful  one,  or  if  the 
system  is  already  as  much  under  the  influence  of  quinine 
as  it  can  conveniently  bear  ; for  we  know  that  if  quinine 
be  given  in  large  doses,  during  open  febrile  excitement, 


CONGESTIVE  FEVER— TREATMENT— QUININE. 


223 


it  acts  as  a powerful  sedative  in  controlling  the  fever. 
When  quinine  is  pushed  too  far,  is  overworking  the  ner- 
vous system,  the  brain  indicates  this  overworking  by 
roaring  in  the  head,  sounds  like  guns  being  fired  off  in 
it,  or  the  roar  of  thunder,  &c.;  the  patient  is  at  the  same 
time  very  restless,  turns  from  side  to  side,  and  throws  his 
limbs  here  and  there,  not  seeming  to  care  if  he  throw 
them  with  some  force  against  the  bedstead  or  other  hard 
substance,  which  would,  under  other  circumstances,  hurt 
them ; he  is  much  oppressed,  desires  the  room  to  be 
freely  ventilated,  and  also  desires  to  be  fanned ; to  have 
cold  water  to  drink,  which  probably  the  irritable  stomach 
may  soon  reject ; and,  perhaps,  also  desires  some  of  it 
sprinkled  on  his  face  and  breast ; perhaps  he  will  get  up 
and  rush  to  the  door  or  window  to  breathe  the  cool  air, 
or  go  to  another  bed,  if  he  do  not  stagger  and  fall  on  the 
floor. 

When  the  patient  is  in  this  condition,  give  him  a large 
dose  of  calomel,  say  from  twenty  to  forty  grains,  with  a 
grain  of  morphine ; this  tends  to  allay  the  irritability  of 
the  stomach,  and  otherwise  acts  favorably.  Strip  the 
patient,  and  pour  cold  water,  first  over  his  head,  neck, 
and  shoulders,  and  then  freely  and  repeatedly  all  over 
him,  till  this  morbid  condition  is  controlled.  After  the 
water  has  pretty  well  accomplished  the  desired  object, 
constantly  fanning  the  patient  will  afford  much  relief. 
If  the  calomel  should  not  act  on  the  bowels  in  twelve  or 
eighteen  hours,  a dose  of  calomel  (ten  grains)  and  jalap 
(ten  grains),  or  something  of  the  kind,  should  be  given. 
Such  cases  as  these  are  dangerous,  but  a prompt  resort 
to  the  means  here  recommended  may  soon  bring  about 
an  amelioration  of  the  symptoms,  and  you  may  save  the 
life  of  your  patient. 

The  diet , in  congestive  fever,  should  be  of  a moderately 
nourishing  quality,  allowed  in  such  quantities  as  are 


224 


REMITTENT  FEVER. 


agreeable  and  acceptable  to  the  stomach,  and  taken 
from  three  or  four  to  five  or  six  times  a day  ; if  often,  it 
should  be  given  in  small  quantities.  The  object  should 
be  to  nourish  and  strengthen  the  patient,  without  over- 
loading and  oppressing  the  stomach,  which  would  have 
a contrary  effect.  Beef,  chicken,  or  squirrel  soup,  or 
something  of  the  kind,  made  palatable  with  salt,  pepper, 
&c.;  coffee,  rice,  or  rice  and  chicken  soup,  etc.  etc.,  may 
answer  this  purpose — consulting  the  patient’s  desires 
and  partialities ; not  allowing,  however,  such  articles  as 
would  manifestly  be  injurious.  Usually,  little  or  no  food 
is  desired  till  convalescence  is  established. 


CHAPTER  XVIII. 

REMITTENT  FEVER,  SOMETIMES  ERRONEOUSLY  CALLED 
BILIOUS  FEVER. 

In  its  attack,  remittent  fever  may  be  primary,  or  it 
may  be  sequent  to  intermittent  or  congestive  fever.  Well 
marked  cases  of  intermittent  and  remittent  fevers  are 
easily  distinguished  from  each  other ; but  it  is  often  the 
case  that  one  runs  so  gradually  into  the  other,  that  at 
times  it  is  difficult  under  which  head  to  place  either ; 
indeed,  it  may  be  said  to  be  intermediate,  partaking  of 
the  nature  of  each  for  a time,  till  the  one  or  the  other  be- 
comes more  distinctive.  An  intermittent  may  suddenly 
assume  a remittent  form ; but  most  commonly  the  ex- 
acerbation, or  hot  stage  of  an  intermittent,  becomes  more 
and  more  protracted,  till  it  merges  into  the  remittent 
form  : the  latter,  whether  primary  or  secondary,  may 
yield  and  be  succeeded  by  the  intermittent  form ; or,  by 


REMITTENT  FEVER— CAUSES. 


225 


negligence  or  bad  treatment,  it  may  become  more  and 
more  severe.  A remittent  is  sometimes  easily  changed 
to  an  intermittent  by  a venesection,  and  sometimes  the 
reverse  of  this  occurs.  It  is  very  frequently  the  case  that 
a patient  is  attacked  with  ague  and  fever  while  in  the 
debilitated  condition  which  succeeds  remittent  fever,  es- 
pecially if  tonic  and  other  hygienic  measures  are  not 
persevered  in  till  he  acquires  a considerable  degree  of 
strength  and  vigor. 

o o 

I v ,VA  V tf  _ ' 

Causes. — As  the  causes  of  remittent  fever,  as  well  as 
the  other  forms  of  malarious  fevers,  have  heretofore  en- 
gaged our  attention  in  the  early  part  of  this  work,  a reit- 
eration here  would  be  unnecessary.  Recently,  I have 
received  a notice  of  a work  now  in  press,  by  Dr.  F. 
Fort,  of  Milledgeville,  Georgia.  In  relation  to  the  his- 
tory of  bilious  fever  in  Milledgeville,  and  its  neighbor- 
hood, he  says  : “In  a state  of  nature  this  was  a rich, 
variegated  country,  covered  with  majestic  forests,  and 
tall,  waving  grass.  The  low  lands  on  the  sides  of  the 
streams  were  covered  with  heavy  cane-brakes,  or  un- 
broken beds  of  reeds.  Such  was  Milledgeville  and  the 
contiguous  country,  till  about  the  year  1807,  when  it 
became  the  residence  of  the  white  man.  In  this  state  of 
primitive  grandeur  and  unequaled  beauty,  this  country 
was  decidedly  healthy.  I was  here  soon  after  the  In- 
dian inhabitants  had  left  it.  I witnessed  its  rapid  settle- 
ment; the  destruction  of  its  forests;  the  extermination 
of  its  cane-brakes,  its  reeds,  and  its  grass,  and  the  laying 
bare  of  its  bosom  to  the  sun. 

“ Bilious  fever  appeared  as  suddenly  as  the  face  of 
nature  had  been  changed  by  the  hand  of  man.  For 
eighteen  years  it  was  a formidable  epidemic  during  the 
summer  and  fall  seasons.  The  mortality  was  greatest 
where  the  lands  were  most  fertile.  Milledgeville,  located 


226 


REMITTENT  FEVER— CAUSES. 


on  a spot  of  great  fertility,  was,  perhaps,  the  greatest 
sufferer.  No  tables  of  mortality  were  kept;  but  I can- 
not be  mistaken  in  placing  the  deaths,  from  bilious  fever 
alone,  as  high  as  five  per  cent,  of  its  whole  population 
each  year,  from  1808  to  1812  or  ’13.  This  mortality, 
happening  in  a few  months,  gave  to  the  disease  the  terror 
of  a pestilence.  Forty  years  have  now  elapsed,  and 
great  has  been  the  change  in  the  face  of  this  country. 
It  has  been  reduced  in  many  places  almost  to  sterility. 
Its  gullied  hills,  and  deeply  sanded  bottoms  have  become 
dry.  The  bilious  fever  has  almost  ceased  its  annual 
visit.  The  annual  deaths  in  Milledgeville,  from  this  . 
cause,  which  I have  said  were  at  one  time  as  many  as 
five  in  the  hundred  of  its  population,  have  gradually  di- 
minished, so  that  within  the  last  five  years  they  have 
not  exceeded  one  in  two  thousand.  The  facts,  which 
have  attended  this  great  change,  cannot  be  uninterest- 
ing.”  Dr.  Fort  then  proceeds  to  speak  of  the  causes  as 
follows  : “ If  there  were  no  summer,  there  would  be 
no  bilious  fever.  But  to  what  degree  the  thermometer 
shall  rise,  or  how  long  continue  at  any  degree  of  heat 
to  produce  this  disease,  is  not  ascertained.  The  process 
is,  I think,  not  sudden.  I have  seen,  in  the  month  of 
June,  the  river  overflow  its  banks,  and  subside  under 
the  greatest  heat  of  summer.  No  fever  appeared  in  five 
or  six  weeks,  but  its  onset  w7as  then  sudden  and  violent, 
and  it  only  subsided  on  the  coming  of  frost.  No  ex- 
ample is  given  of  the  appearance  of  this  disease  in 
winter,  except  in  persons  who  had  contracted  it  before- 
hand ; nor  is  it  agreed  what  length  of  time  the  infection 
may  remain  in  the  system. 

“ So  far  as  it  regards  climate,  it  appears  that  summer 
heat  and  moisture  must  combine  to  produce  bilious  fever ; 
before  absolute  dryness,  or  thorough  wet,  it  equally  dis- 
appears. I have  seen  bilious  fever  appear  in  July,  dis- 


REMITTENT  FEVER— CAUSES. 


227 


appear  in  the  driest  and  hottest  weather  of  August,  and 
reappear  on  the  coming  of  rainy  weather  in  the  next 
months.  These  observations  are  not  new.  In  the  East, 
it  has  been  remarked  that  the  overflowing  of  the  delta 
of  the  Ganges  and  Indus,  is  the  signal  of  returning  health 
to  their  inhabitants.” 

Professor  Dickson,  formerly  of  Charleston,  South 
Carolina,  now  of  New  York,  remarks,  that  bilious  remit- 
tent fever  is  “ the  endemic  scourge  of  certain  well-known 
localities,  in  which  it  is  not  unfrequently  aroused  into 
epidemic  and  pestilential  sway.” 

Dr.  Stephen  N.  Harris,  of  Georgia,  makes,  in  sub- 
stance, the  following  remarks;  as  I have  not  his  paper  be 
fore  me,  I do  not  vouch  that  they  are  precisely  verbatim. 
He  is  of  opinion  that  malarious  fever  may  be  modified 
by  the  influences  concerned  in  producing  typhus  fever. 
The  late  Professor  Dewees  believed  that  typhus,  wrhen 
simple,  is  always  of  the  continued  form.  Should  the  pa- 
tient, however,  have  been  exposed  to  miasm,  it  may  cause 
typhus  to  assume  a disposition  to  remit,  but  not  without. 
The  subject  is  one  of  interest,  as  showing  the  mixed  phe- 
nomena of  combined  agencies.  Dr.  Harris  believes  ma- 
lignant remittent  fever  to  be  a combination  of  typhoid  and 
malarious  fever,  with  local  irritation  or  inflammation. 
This  hypothesis  is  questionable. 

In  the  length  and  severity  of  its  exacerbations,  other 
phenomena,  and  remissions,  remittent  fever,  perhaps 
almost  invariably,  manifests  its  analogy  to  intermittent 
fever,  by  the  observance  of  the  quotidian,  double  tertian, 
triple  tertian,  or  other  types.  For  instance,  it  is  well 
known,  and  often  observed,  by  persons  who  attend  on 
those  who  have  remittent  fever,  that  the  patient  will  be 
worse  every  other  day,  and  so  on. 


228 


REMITTENT  FEVER— MILD  FORM. 


FORMS  OF  REMITTENT  FEVER. 

From  practical  observation,  I believe  Remittent  Fever 
may  conveniently  be  considered  under  the  four  following 
forms,  namely  : — 

1st.  The  Mild,  or  Simple  Form. 

2d.  The  Causus,  or  Inflammatory  Form. 

3d.  The  Nervous,  or  Comatose  Form. 

4th.  The  Typhoid,  or  Dysenteric  Form,  or  Stage. 

One  or  other  of  these  forms  are  generally  well  marked 
and  sufficiently  distinctive,  but  it  should  be  observed  that 
some  cases  may  hold  an  intermediate  link. 

1st.  The  Mild,  or  Simple  Form. — This  form  may 
succeed  to  intermittent  or  congestive  fever,  or  it  may  be 
primary.  Th e premonitory  symptoms  and  corresponding 
phenomena  are  analogous,  if  not  identical,  to  those  of  in- 
termittent fever.  A feeling  of  malaise , dullness,  and, 
perhaps,  slight,  dull,  obscure  pains  in  the  back  and  lower 
limbs  or  shoulders  and  head,  may  precede  an  attack  for 
several  days  ; or  the  forming  stage,  or  stage  of  oppression, 
may  appear  without  these  premonitions.  This  stage 
usually  makes  its  appearance  with  hebetude,  lassitude, 
aching  in  the  loins,  hips,  and  knees,  in  the  head,  per- 
haps vertigo,  and  occasional  fugitive  pains  elsewhere ; 
the  extremities  become  cold ; the  face  may  be  pale  and 
features  contracted,  or  the  face  may  present  more  or  less 
fullness  and  redness;  a chill  or  rigor  less  or  more  manifest 
may  ensue,  with  interrupted,  increased,  and  oppressed 
respiration  ; pulse  small,  quicker  than  natural,  feeble  and 
variable;  thin,  whitish  coat  on  the  tongue,  towards  the 
root  of  it,  which  gradually  disappears  near  the  tip  and 
edges,  or  rather  becomes  more  and  more  faint  there. 
Usually,  there  is  an  indescribable,  unpleasant  sensation 


REMITTENT  FEVER— MILD  FORM. 


229 


in  the  stomach  and  anorexia;  the  bowels  are  commonly 
inclined  to  costiveness,  but  not  always. 

After  a time,  reaction  gradually  manifests  itself ; the 
chilly  sensations  may  have  continued,  and  now  alternate 
with  flushes  of  heat ; the  general  surface  and  extremi- 
ties  become  warm,  and  are  dry ; the  features  become 
more  full  and  red,  but  usually  only  moderately  so;  the 
eyes  may  look  somewhat  reddish,  and,  in  some  cases, 
yellowish;  the  pulse  becomes  more  full,  but  not  hard, 
and  perhaps  not  more  frequent,  or,  in  some  cases,  even 
less  so  than  during  the  earlier  part  of  the  forming  stage  ; 
the  mouth,  which  was  in  the  previous  stage  rather 
moist  and  clammy,  becomes  more  dry,  and  the  tongue 
redder  at  the  tip  and  edges;  and,  after  the  febrile  condi- 
tion lasts  for  some  time,  the  whitish  fur  extends,  and  be- 
comes of  a whitish  yellow,  yellowish,  and,  still  later  in 
the  disease,  of  a yellowish  brown,  or  brown  hue;  the 
respiration  is  now  more  easy,  though  still  somewhat 
oppressed,  with  an  occasional  deep  inspiration  or  sigh  ; 
generally  there  is  more  or  less  anxiety  and  restlessness  ; 
commonly  thirst,  but  not  invariably  so;  usually  dull, 
aching  pains  in  the  lumbar  region,  lower  extremities, 
neck,  and  head  ; the  painful  sensation  in  the  stomach  is 
sometimes  attended  with  nausea  and  vomiting  of  a ropy 
mucous  and  yellowish  bile,  especially  if  the  vomiting 
continues  for  some  time.  In  some  cases,  the  skin,  in 
addition  to  being  warm,  or  hot  and  dry,  is  tinged  with  a 
yellowish  hue. 

After  this  febrile  condition  reaches  its  acme,  which  it 
usually  does  in  a few  hours,  and  most  commonly  in  the 
afternoon,  and  which  is  not  often  high  in  this  form, 
it  gradually  abates,  lasting  from  nine  to  eighteen  hours, 
till  some  transient  perspirations  occasionally  take  place, 
especially  about  the  head  and  upper  part  of  the  chest, 


230 


REMITTENT  FEVER— MILD  FORM— CAUSUS. 


and  the  general  surface  assumes  a natural  temperature, 
or  nearly  so.  Now  comes  the  period  of  remission , which 
is  of  longer  or  shorter  duration,  and,  in  a large  majority 
of  cases,  takes  place  early  in  the  morning,  during  which 
time  the  patient  feels  much  better,  in  many  instances 
nearly  or  quite  well,  and  may  have  some  appetite. 
After  this  remission  lasts  for  a time,  the  feet  and  hands 
usually  become  cooler  than  natural,  which  is  again  fol- 
lowed by  reaction,  the  fever  beginning  gradually  to  rise. 
If  nothing  has  been  taken  to  modify  it,  the  excitement 
at  this  time  will  probably  be  greater  than  in  the  previous 
paroxysm. 

Thus  the  fever  may  continue,  from  day  to  day,  till  it 
runs  its  course,  w'hich  may  occupy  one  or  two  weeks,  or 
it  may  merge  into  intermittent  fever;  or  the  paroxysms 
may  become  more  and  more  severe  and  protracted,  and 
merge  into  one  of  the  other  forms  of  remittent  fever  ; 
but,  almost  invariably,  under  timely  and  proper  treat- 
ment, it  may  be  arrested  in  a day  or  two,  or,  if  ne- 
glected for  a few  days,  it  may  require  several  days  to 
arrest  it. 

Second  Form — The  Causus.* — The  causus,  syno- 
chal,  or  inflammatory  form,  may  appear  like  an  ordi- 
nary intermittent,  or  like  the  first  form  of  remittent 
fever,  but  frequently  makes  its  appearance  without  any 
previous  chill  or  rigor.  In  this  form,  the  stage  of  reac- 
tion is  much  more  violent,  with  greater  determination  to 
certain  organs,  the  most  common  of  which  are  the  brain 
and  spinal  marrow,  lungs,  stomach  and  bowrels,  liver, 
spleen,  &c.  &c.;  but  these  determinations  (irritation,  in- 
flammation, or  congestion,  or  these  variously  combined) 
are  far  from  being  uniform,  sometimes  predominating  in 


* Causus  is  derived  from  the  Greet,  signifying  “ I burn." 


REMITTENT  FE  VER— CAUSUS. 


231 


one  organ  or  organs,  and,  in  other  cases,  some  other 
organ  or  organs  being  most  prominently  affected,  each 
being  distinguished  by  corresponding  symptoms;  if 
the  brain  is  much  affected  (whose  functions  are  of 
the  greatest  importance),  it  will  be  indicated  by  pain 
in  the  head,  or  headache,  more  or  less  intense,  with 
a sensation  of  fullness  or  determination  to  the  head, 
throbbing  of  the  carotid  and  temporal  arteries,  confusion 
of  mind,  perhaps  slight  delirium,  vertigo,  intolerance  of 
light  and  sound  ; or  the  patient  may  be  stupid,  dull,  and 
inclined  to  doze  or  sleep.  In  this  form  of  remittent  fever 
the  respiration  is  hurried,  irregular,  and  uneven  ; and, 
according  to  the  extent  of  the  pulmonic  complication, 
there  will  be  pain  and  a sensation  of  stricture  in  the 
chest,  which  is  increased  by  a full  inspiration  ; and  the 
respiration  will  be  more  or  less  laborious  and  painful ; 
the  countenance  will  be  more  anxious,  and  the  face  of  a 
more  or  less  purplish  or  livid  hue;  and  this  pulmonary 
complication,  when  of  great  extent,  or  protracted,  has  an 
influence  on  the  pulse,  making  it  feeble,  irregular,  and 
inelastic  ; or,  perhaps,  it  would  be  more  proper  to  regard 
these  as  cotemporary,  and  referable,  in  a great  measure, 
to  the  same  cause.  According  to  the  extent  of  the  im- 
plication of  the  spinal  marrow,  or  any  particular  portions 
of  it,  will  be  the  pain  or  aching  in  the  back,  soreness 
and  aching  of  the  limbs,  and  muscular  debility  ; with 
perhaps  more  or  less  soreness  in  every  part  of  the  body; 
in  some  cases  tingling  sensations  in  the  extremities,  par- 
tial paralysis,  dysuria,  &c.  If  the  base  of  the  brain 
about  the  medulla  oblongata , and  the  upper  portion  of  the 
spinal  marrow,  from  which  nerves  arise  and  are  distri- 
buted to  the  thorax,  are  much  affected,  we  may  expect  to 
find  corresponding  pulmonary  distress,  and  complica- 
tion. If  the  spinal  cord  is  more  prominently  affected 
lower  down,  we  may  observe  corresponding  implications 


232 


REMITTENT  FEVER— CAUSUS. 


of  the  contents  of  the  abdomen ; or,  if  still  lower  down, 
the  lower-extremities,  and  perhaps  some  of  the  contents 
of  the  pelvis,  are  correspondingly  affected,  great  muscu- 
lar debility,  &c.  According  to  the  extent  of  the  impli- 
cation of  the  stomach,  will  there  be  irritability,  nausea, 
perhaps  vomiting,  a sensation  of  pain,  soreness,  distress, 
or  an  uncomfortable  sensation,  oppression,  or  weight,  or 
an  indescribable  uneasiness  and  heat  in  the  region  of  the 
stomach;  in  a large  majority  of  cases,  the  thirst  is  very 
great,  the  patient  desiring  cold  drinks  almost  incessantly. 
When  vomiting  takes  place,  any  food  that  may  be  in  the 
Stomach,  with  water  and  mucus,  is  first  thrown  up;  if 
the  puking  continues  for  some  time  (or  it  is  occasionally 
the  case  at  the  commencement),  yellowish  bile,  in  some 
cases  greenish,  blue,  dark  brown,  &c.,  is  thrown  up, 
which  affords  temporary  relief.  The  bowels  are  generally 
costive,  but,  in  some  cases,  the  patient  is  troubled  with 
tormina,  tenesmus,  thin,  acrimonious,  offensive,  and  fre- 
quent stools.  If  the  liver  is  much  affected,  it  will  be  in- 
dicated by  a sensation  of  fullness  and  pain,  especially  if 
pressure  be  made  over  the  region  of  it,  in  the  right  hypo- 
chondriac region,  which  lies  to  the  right  of  the  stomach. 
In  some  cases  there  is  concomitant  pain  in  the  shoulder, 
but  perhaps  this  latter  is  not  the  effect  of  the  impli- 
cation of  the  liver,  as  has  been  supposed  by  many,  but 
dependent  on  implication  of  the  spine,  about  the  cervi- 
cal region ; or,  indeed,  by  reflex  action,  the  morbid  con- 
dition of  the  liver  may  be  the  cause  of  this  pain  by 
first  causing  a morbid  condition  in  the  corresponding 
portion  of  the  spinal  marrow.  The  spleen,  pleura,  and 
other  parts,  may  also  suffer  from  their  nervous  implication 
and  determination  to  them  ; the  kidneys,  too,  are  more  or 
less  implicated,  and  the  urine  scanty  and  high  colored. 
The  general  surface  is  hot  and  dry,  and  expanded  or  full, 
the  superficial  vessels  being  full  and  prominent ; the  face 


REMITTENT  FEVER— CAUSUS. 


233 


is  flushed  and  turgid ; eyes  red  and  suffused  ; countenance 
expressive  of  anxiety  and  distress;  restlessness  and  turn- 
ing from  side  to  side,  or  dullness  and  inclination  to  doze 
or  sleep.  The  tongue  is  of  a bright  red  at  the  tips  and 
edges,  and  covered  at  first  with  a white  fur,  which 
soon  changes  to  a whitish  yellow,  and  then  to  a yel- 
lowish brown,  and  brown.  The  pulse  presents  some 
variety;  in  the  more  northern  portion  of  the  United 
States,  in  those  who  have  recently  emigrated  to  the 
South,  and  in  those  of  a vigorous  and  sanguine  temper- 
ament, it  is  full,  more  or  less  hard  and  bounding,  and 
commonly  from  about  90  to  112  or  125  beats  in  a minute. 
In  those  who  are  residents  in  the  more  southern  portions 
of  this  Union,  the  pulse  is  less  full,  and  less  hard  and 
bounding;  it  may,  indeed,  be  rather  small,  with  not 
much  hardness,  compressible,  with,  perhaps,  some  ab- 
ruptness and  irregularity,  usually  from  about  90  to  110 
or  115  per  minute. 

This  febrile  condition  may  last  from  twelve  to  twenty 
hours,  when  the  period  of  remission  gradually  makes 
its  appearance,  with  relief  of  all  the  distressing  attend- 
ants. If  this  is  slight,  perhaps  there  will  be  but  little 
moisture  on  the  temples,  about  the  face  and  upper 
part  of  the  chest  or  neck;  which,  however,  if  it  does 
occur,  is  transient.  If  the  remission  is  more  marked, 
a pretty  free  perspiration  may  appear  all  over  the  gene- 
ral surface,  and  the  patient  may  fall  asleep  and  enjoy  a 
tolerably  comfortable  slumber — during  which  he  will  be 
apt  to  have  some  distressing  and  frightful  dream ; or, 
indeed,  though  rarely,  in  the  first  or  second  remission, 
the  fever  may  be  entirely  absent,  making  a complete  in- 
termission, and,  for  a few  hours,  the  patient  may  feel 
almost  well. 

After  a remission  more  or  less  complete,  and  of  a 
longer  or  shorter  duration,  the  febrile  condition  again 
16 


234 


REMITTENT  FEVER— NERVOUS  FORM. 


gradually  comes  on,  or  increases,  generally  with  augmen- 
tation of  all  the  distressing  phenomena  which  attended 
the  previous  paroxysm  ; and  if  the  proper  treatment  is  not 
soon  resorted  to,  exhaustion  and  prostration  of  the  vital 
powers,  with  local  lesions,  corresponding  with  the  pre- 
vious determinations  to  certain  organs,  may  occur.  Thus, 
this  variety  may  last  from  a few  to  about  twelve  days, 
the  patient  becoming  more  and  more  prostrated,  the  vital 
powers  gradually  failing  till  death  closes  the  scene ; or  he 
may  sink  into  the  third  or  fourth  form,  or  variety  of  re- 
mittent fever;  or  each  succeeding  paroxysm  may  be 
lighter  and  lighter,  till,  in  from  seven  to  len,  twelve,  or 
fourteen  days,  convalescence  may  take  place,  and  the 
individual  slowly  recover. 

The  causodes  is  but  a milder  form  of  the  causus. 

Third  Form. — The  Nervous  or  Comatose  Form  or 
variety  of  remittent  fever,  is  evinced  by  great  prostration 
and  debility,  neuroblacia,  or  diminished  sensibility  of  the 
nervous  system,  stupor,  with  a continued  disposition  to 
doze  or  sleep,  from  which  the  patient  maybe  aroused  by 
calling  loudly,  or  by  shaking  him,  in  very  severe  cases; 
but  he  soon  relapses  again  into  the  comatose  condition. 
He  seldom  or  never  complains  of  any  pain.  If  asked 
how  he  is,  he  replies,  “ tolerably  well,”  “ very  well,”  or 
what  amounts  to  the  same ; and  almost  immediately  drops 
off  into  a doze.  Expression  of  the  countenance  and  eyes 
dull,  the  eyes  somewhat  sunken,  the  white  of  them  mo- 
derately injected,  or  of  a dull  reddish  hue,  generally ; the 
face  has  a narrow  and  contracted  aspect,  especially  after 
the  fever  has  lasted  for  several  days;  audition  is  impaired 
— dull ; the  skin  is  warm,  or  rather  hot,  and  obstinately 
dry ; the  pulse  for  the  first  three  days  is  usually  slightly 
increased  in  fullness  and  frequency,  but  yielding  under 
the  finger;  afterwards  becoming  weaker,  and,  in  some 


REMITTENT  FEVER— NERVOUS  FORM. 


235 


instances,  slower,  even  below  the  natural  standard  ; the 
mouth  is  inclined  to  be  rather  dry  ; frequently  but  little, 
moderate,  or  no  thirst,  till  towards  the  latter  period  of  the 
disease,  or  on  the  eve  of  convalescence,  when  the  desire 
for  cold  water  is  considerably  increased.  The  tongue  is 
covered,  at  first,  with  a -white  fur,  which  soon  becomes 
yellow,  then  yellowish-brown,  or  dark,  and  very  thick, 
rough,  and  dry  ; the  tip  and  edges  are  increased  in  red- 
ness ; the  urine  is  scanty  and  high  colored ; the  bowels 
are  usually  costive  (but  respond  to  cathartics  without 
much  difficulty),  with  borborigmus  or  rumbling  in  them, 
which  latter  increases  as  the  disease  advances.  For  the 
first  three  or  four  days  there  is  fullness  in  the  region  of 
the  stomach  and  abdomen,  with,  perhaps,  in  some  cases, 
over  the  region  of  the  liver  also.  This  fullness  of  the 
stomach  and  abdomen  subsequently  subsides,  and  the 
abdomen  is  flattened,  instead  of  presenting  a fullness  or 
prominency.  In  many  cases  there  is  scarcely  any  re- 
mission perceptible  till  the  third  or  fourth  day,  when  the 
feet  and  hands  may  be  observed  to  get  cool  (especially  if 
uncovered),  and  remain  so  for  a while — say  an  hour  or 
two,  or  longer,  once  a day;  which  most  frequently  takes 
place  about  ten  or  eleven  o’clock  in  the  morning. 

This  form  of  remittent  fever,  or  some  of  its  modifi- 
cations, is,  perhaps,  that  which  is  termed  by  medical 
writers  “ congestive  remittent In  some  of  these  modi- 
fications, the  reactions  are  more  manifest,  or  consider- 
ably greater,  and  the  remissions  more  distinct;  there 
is  also  more  anxiety  and  restlessness,  especially  when 
the  period  of  congestion  comes  on,  and  in  a less  de- 
gree, perhaps,  during  the  subsequent  febrile  excite- 
ment. In  some  cases,  in  which  there  is  determination 
to  an  important  organ,  as  the  stomach  or  brain,  for  in- 
stance, there  is  severe,  agonizing  pain  ; which,  however, 


236 


REMITTENT  FEVER— TYPHOID  FORM. 


is  greatly  modified  or  entirely  absent  in  the  period  of  re- 
mission, except  pressure  is  made  on  it,  as  in  case  of  the 
stomach,  etc.  If  these  repeated  congestions  are  not  ar- 
rested, the  organ  so  affected  will  become  more  and  more 
deeply  involved,  and  death  may  ultimately  ensue ; but 
with  prompt  and  proper  treatment  the  morbid  action 
may  soon  be  controlled,  and  convalescence  established. 
Large  doses  of  quinine  and  opium,  and  an  occasional 
dose  of  calomel  (from  ten  to  twenty  grains  once  in  twenty- 
four  hours),  are  the  principal  remedies  to  be  relied  upon. 

In  severe  and  protracted  cases,  there  is  low,  muttering 
delirium,  picking  at  the  bed-clothes,  or  imaginary  things; 
parched,  dry  skin;  quick,  wiry  pulse;  dark,  dry  tongue, 
and  dark  sordes  about  the  teeth ; the  urine  discharged 
involuntarily;  the  bowels  costive. 

An  attack  of  this  form  of  remittent  fever  may  be  pri- 
mary, or  it  may  succeed  the  intermittent,  or  either  of 
the  two  forms  of  remittent  fever  which  we  have  already 
considered,  especially  the  second  — the  causus.  This 
is  justly  considered  a dangerous  form  of  remittent  fever, 
requiring  strict,  close,  and  constant  attention.  It  may 
terminate  fatally  in  eight  or  twelve  days,  or  assume  the 
typhoid  or  fourth  form  or  variety  of  remittent  fever.  But, 
under  timely  and  proper  treatment  and  attention,  it  may 
generally  be  cured — rarely  prove  fatal ; yet,  even  under 
the  best  management,  it  is  apt,  in  many  cases,  to  be  te- 
dious and  protracted,  lasting  twelve,  fifteen,  or  twenty 
days,  sometimes  longer,  before  convalescence  is  com- 
pletely established.  In  milder  cases,  it  may  be  arrested 
in  a few  days. 

Fourth. — The  Typhoid  Form,  or  Stage  of  Remit- 
tent Fever,  is  usually  sequent  to  the  second  (causus)  or 
third  (nervous  or  comatose)  forms ; but  in  consequence 


REMITTENT  FEVER— TYPHOID  FORM. 


237 


of  improper  treatment,  especially  the  use  of  irritating  ca- 
thartics, it  may  be  brought  on  in  the  first  (simple  or 
mild)  form  ; or  it  may  be  induced  in  this  manner  in  the 
treatment  of  intermittent  fever;  and,  under  these  circum- 
stances, in  its  early  stages,  is  frequently  attended  by  very 
severe,  griping  pains  in  the  abdomen.  It  may  be  brought 
on  in  the  first  few  days  after  an  attack  of  either  of  the 
other  forms  of  remittent  fever,  but  it  most  commonly 
makes  its  appearance  from  the  sixth  to  the  twelfth  day  ; 
and,  if  it  does  not  sooner  terminate  fatally,  it  may  last  two 
or  three  weeks,  or  even  longer.  Prof.  Dickson  says  he 
has  “known  cases  protracted,  in  three  instances,  to  30,  35, 
and  50  days,  though  the  average  would  scarcely  reach 
beyond  15  or  20.” 

This  form  or  stage  of  remittent  fever  is  indicated  by 
the  following  symptoms  : Decubitus,  generally  dorsal,  or, 
in  other  words,  lying  on  the  back,  with  a disposition  to 
slide  down  towards  the  foot  of  the  bed,  sometimes  with 
the  knees  drawn  up ; the  cheeks  are  usually  of  a pur- 
plish or  brownish  red  flush,  which  is  increased  or  be- 
comes more  prominently  developed  once  a day,  gene- 
rally about  two  or  three  o’clock,  P.  M.,  and  lasts  for 
several  hours ; this  is,  in  many  cases,  more  manifest 
every  other  day,  the  patient  being  worse.  There  is 
a disposition  to  coma  and  stupor,  with  muttering  deli- 
rium, from  which  the  patient  may  be  aroused  by  speak- 
ing rather  loudly  to  him.  The  countenance  is  haggard 
and  dull ; the  eyes  sunken  and  nearly  closed ; the  fore- 
part of  the  eyeball  being  drawn  up  under  the  upper 
eyelid,  so  as  to  make  visible  the  white  and  lower  part 
of  the  eye.  The  heat  of  the  general  surface  is  often 
but  slightly,  if  at  all,  increased,  except  for  the  first  few 
days  after  the  attack ; in  many  cases  higher  over  the 
abdomen,  chest,  and  head,  and  is  commonly  dry,  with 
occasional  moisture  about  the  temples;  or  perhaps  it 


238 


REMITTENT  FEVER— TYPHOID  FORM. 


extends  over  the  body,  but  is  frequently  only  of  short 
duration.  In  severe  cases,  petechiae,  or  small  red  spots, 
like  flea-bites,  appear  on  the  body,  and  may  extend  to 
the  face  and  forehead.  The  feet  and  hands  are  inclined 
to  become  cool,  especially  if  uncovered ; and,  like  the 
other  forms,  I believe  this  is  most  likely  to  occur  about 
10  or  11  o’clock  in  the  morning.  The  pulse  is  increased 
in  frequency,  small,  in  some  instances  corded,  but  almost 
invariably  feeble,  compressible,  yielding  under  slight 
pressure  of  the  finger;  though,  in  some  cases,  especially 
in  the  earlier  stages,  there  is  some  degree  of  fullness. 
The  tongue  is  dry  and  chapped,  and  covered  with  a 
brown  or  dark  coat,  which  in  many  cases  is  subsequently 
thrown  off,  exposing  to  view  a rather  smooth,  red,  and 
dry  surface ; when  thrust  out,  it  is  pointed  and  tremulous, 
and  the  tip  and  edges  are  very  red  ; in  the  latter  period 
of  the  disease,  there  are  dark  sordes  on  the  teeth,  and  in 
some  cases  on  the  lips.  The  stomach  will  generally  re- 
tain medicines  without  much  difficulty,  but  it  is  at  times 
irritable,  and  nausea  and  vomiting  are  easily  provoked ; 
there  is  a disposition  to  frequent,  copious,  watery,  colli- 
quative, alvine  discharges,  w'hich  are  usually  of  a brown- 
ish appearance,  sometimes  resembling  the  wrashings  of 
beef,  the  odor  of  which  is  sometimes  very  offensive; 
borborigmus,  or  a rumbling  noise  in  the  abdomen,  per- 
haps always  attends,  in  a greater  or  less  degree,  and 
in  many  cases  meteorism,  tympanites,  or  fullness  and 
hardness  of  the  abdomen.  There  are  great  languor, 
debility,  and  prostration  of  the  vital  powers;  subsultus 
tendinum , and  nervous  tremors,  on  motion.  The  patient 
seldom  complains  of  any  griping  in  the  bowels,  except 
in  the  earlier  stages  of  the  disease.  Sometimes  there  is 
giddiness,  tinnitus  aurium , or  roaring  in  the  ears  or 
head.  The  urine  is  high  colored,  and  at  times  of  an  of- 


REMITTENT  FEVER— TYPHOID  FORM. 


239 


fensive  smell.  Dull  moaning,  stertorous  breathing,  hic- 
cough, and  involuntary  discharges  are  ominous  of  an 
unfavorable  termination,  but  there  may  be  recoveries  in 
such  cases  if  the  proper  treatment  is  promptly  and  vi- 
gorously persevered  in ; but  when  are  added  to  these 
unfavorable  symptoms  a disposition  to  faint  whenever 
the  head  is  raised  up,  a cadaverous  sweat,  or  hemor- 
rhages or  bleeding  from  the  bowels,  stomach,  nose,  etc., 
the  case  will  soon  terminate  in  death. 

This  form  or  stage  of  remittent  fever  occurs  much 
more  frequently  than  the  third  ; and  I have  no  doubt 
but  it  is  most  frequently  brought  on  by  the  abuse  of 
cathartic  medicines,  and  neglecting  to  treat  the  prior 
stages  of  the  fever  properly. 

This  form  of  remittent  fever  closely  resembles  the 
genuine  typhoid  fever,  so  much  so,  indeed,  as  to  make 
it  plausible  to  suppose  that  the  causes  of  each  may  be 
so  combined  as  to  give  this  character  to  the  disease. 
Professor  J.  P.  Harrison,  of  Cincinnati,  Ohio,  says,  that, 
“ in  this  typhoid  state,  there  exists  a lesion  of  the  mucous 
coat  of  the  lower  portion  of  the  ileum.  This  lesion,  at 
first  inflammatory,  becomes  ulcerative,  and  often  destroys 
the  life  of  the  patient  by  perforation  of  the  entire  intesti- 
nal tube.”  And  he  further  remarks  : “ Permit  me  to 
notice  here,  in  a passing  way,  the  close  resemblance 
which  the  typhoid  stage  of  bilious  fever  bears  to  genuine 
typhoid  fever.  The  structural  lesion  of  the  agtninated 
glands  of  the  ileum  is  very  similar,  as  you  will  perceive 
by  this  specimen,  taken  from  a subject  who  died  of  a 
protracted  attack  of  bilious  remittent  fever.  You  per- 
ceive the  ulceration  along  the  lower  third  of  the  ileum  ; 
here  is  one  point,  in  which  there  is  an  almost  entire  per- 
foration of  the  intestinal  tube.  Still,  I do  not  contend  for 
the  identity  of  the  typhoid  stage  of  bilious  remittent 


240 


REMITTENT  FEVER— PROGNOSIS. 


fever  and  genuine  typhoid  fever.”*  Some  years  ago. 
Professor  Harrison  affirmed  that  inflammation,  termina- 
ting in  ulceration,  is  a frequent  sequel  in  protracted 
attacks  of  bilioust  remittent  fever,  and  that  the  ulcera- 
tion is  commonly  found  in  the  glands  of  Peyer  at  the 
lower  end  of  the  ileum. 

The  Prognosis  in  Remittent  Fever  generally,  and 
especially  when  timely  and  proper  treatment  is  resorted 
to,  may  be  said  to  be  favorable,  though  in  some  locali- 
ties, and  in  different  years,  it  appears  as  an  endemico- 
epidemic,  and  sometimes  assumes  a more  than  usually 
malignant  type.  Professor  Dickson  says:  “From  all 
that  I can  learn  on  the  subject,  I am  not  disposed  to 
rate  the  proportion  of  deaths  within  our  city  (Charleston) 
at  more  than  one  in  thirty.”  The  Professor  then  pays  a 
compliment  to  the  practitioners  in  the  South  and  South- 
West,  in  the  following  language,  from  which  we  mav 
infer  that  the  mortality  in  the  North  is  much  greater. 
He  says:  “From  the  authentic  records  of  its  mortality, 
it  is  certain  that  the  proportional  success  of  the  modes  of 
treatment  in  the  South  and  South-West,  must  be  greater, 
or  that  the  violence  and  fatal  tendency  shown  by  the  dis- 
ease must  be  less  than  in  other  malarious  regions.”  I 
believe  all  writers,  both  northern  and  southern,  regard 
the  remittent  fevers  of  the  South  as  much  more  violent 
and  severe  than  the  same  disease  occurring  in  the  North. 

* In  a clinical  lecture  to  his  class  in  1848.  West.  Lancet,  April,  1848. 

f I regret  to  see  that  such  men  as  Professors  Harrison  and  Dickson  con- 
tinue to  use  the  designation  “ Bilious  Remittent  Fever;”  not  only  because 
it  is  erroneous,  the  liver,  in  a large  majority  of  cases,  being  much  less  im- 
plicated than  other  parts,  hut  because  also  it  leads  themselves,  and  many 
of  those  students  who  regard  this  teaching  as  orthodox,  to  a too  liberal 
and  indiscriminate  use  of  calomel  and  blue  mass : a practice  which  has 
been  inculcated  by  Dr.  Cooke,  and  others,  and  which  has  been  a great 
curse  to  the  people  of  the  south  and  southwestern  States. 


REMITTENT  FEVER— PROGNOSIS. 


241 


In  1827,  Dr.  Dickson  treated  188  cases,  and  in  1835, 
123  cases,  making  311.  “In  each  year  there  were  three 
deaths,  six  in  all,  making  one  death  in  about  fifty  cases 
taken  promiscuously.”  According  to  my  experience,  in 
those  cases  that  are  properly  treated  death  is  very  rare  in- 
deed, probably  not  more  than  one  in  80  or  100.  Though 
if  neglected,  or  badly  treated,  the  mortality  is  much 
greater,  perhaps  one  in  twenty  or  thirty  proving  fatal. 
These,  however,  are  but  general  remarks ; much  de- 
pends on  the  locality,  and  the  severity  of  the  attack, 
and  other  circumstances,  as  the  exposure  or  comfortable 
situation  of  the  patient,  &c. 

In  the  first  or  simple  form , the  prognosis  is  nearly 
always  favorable  ; but  even  this,  in  certain  highly  mala- 
rious localities,  in  different  years,  now  and  then  requires 
to  be  well  attended  to,  sometimes  suddenly  assuming  a 
more  serious  aspect. 

The  prognosis  in  the  second  form  ( causus ),  depends  on 
the  violence  or  intensity  of  the  disease,  the  extent  of  the 
pathological  lesions  of  important  organs,  and  the  readi- 
ness or  obstinacy  with  which  these  yield  to  treatment. 
These  remarks  also  apply  to  the  other  forms.  Low  mut- 
tering delirium,  picking  at  the  bed-clothes,  or  imaginary 
objects,  subsultus  tendinum,  hiccough,  and  weak,  fre- 
quent pulse,  are  commonly  regarded  as  unfavorable 
symptoms,  though  I have  known  several  to  recover  from 
this  dangerous  condition.  When  are  added  to  these  ex- 
treme prostration,  pulse  so  weak  as  scarcely  to  be  percep- 
tible at  the  wrist,  fainting  easily  induced  by  raising  up  the 
head  of  the  patient  for  a few  moments,  indicative  of  ex- 
treme debility,  the  transparent  part  of  the  eyes  drawn  up 
under  the  upper  lids,  a cadaverous  smell  or  odor,  and 
involuntary  discharges  from  the  bowels,  death  will,  in  all 
probability,  soon  ensue. 

When  there  is  relief  of  all  the  severer  symptoms,  the 


242 


REMITTENT  FEVER— PATHOLOGY. 


remissions  becoming-  more  and  more  distinct  and  length- 
ened,  with  general  and  warm  diaphoresis,  the  patient 
feeling  calm  and  comfortable,  and  the  mind  clear,  we  may 
anticipate  a recovery. 

Pathology. — In  the  early  stage  of  this  disease,  the 
pathological  condition  appears  to  be  analogous  to  that  of 
intermittent  fev^r,  but  is  more  intense  or  tenacious ; or, 
in  other  words,  the  system  is  brought  more  under  the 
control  of  morbid  action,  or  morbid  influences,  with,  of 
course,  less  power  on  the  part  of  the  system  to  overcome 
this  departure  from  a physiological  condition.  Some  are 
of  opinion  that  this  disease  is  brought  on  by  the  influ- 
ence of  heat  and  moisture  ; others  that  it  is  induced  by 
an  imaginary  poison  in  the  atmosphere,  which  they  call 
miasm.  Others,  again,  refer  it  to  other  causes.  But, 
be  the  causes  what  they  may,  the  first  manifestations 
of  disease  which  exhibit  themselves  to  us  are  refera- 
ble to  the  nervous  system.  If  the  disease  is  brought  on 
by  miasm,  this  poison  (if  there  is  such  a thing)  may  be 
inhaled,  and  enter  the  circulation  via  the  lungs,  and, 
during  its  latent  period,  may  be  inducing  a peculiar  pa- 
thological condition  of  the  blood,  which  affecting  the 
whole  body,  to  a certain  degree,  the  nervous  system 
feels  and  informs  us  of  these  morbid  encroachments  by 
a feeling  of  malaise , or  indisposition,  with  a greater  or 
less  degree  of  languor  and  dullness.  Then,  after  a 
longer  or  shorter  period,  unpleasant  sensations  in  the 
stomach,  head,  limbs,  &c. ; a rigor,  or  chilly  sensations, 
most  commonly;  then  comes  reaction  ; or  the  febrile  phe- 
nomena may  make  their  appearance  without  the  chilly 
sensations.  In  either  case,  the  nervous  system,  and  per- 
haps the  blood,  are  morbidly  impressed  ; and  when  such 
is  the  case,  need  we  look  for  uniformity  in  the  pathologi- 
cal conditions  found  on  post-mortem  examinations  1 To 


REMITTENT  FEVER— PATHOLOGY. 


243 


use  the  language  of  Dr.  Billing  : “ From  the  very  nature 
of  Fever,  which  I have  described  to  be  a disease  essen- 
tially affecting  the  whole  nervous  system,  it  follows  that 
the  functions  of  the  viscera  must  be  disturbed  : and 
though,  as  just  pointed  out,  sometimes  disease  of  one 
organ  predominates,  sometimes  of  another,  yet  every 
organ  suffers  more  or  less  congestion  in  every  fever,  from 
the  loss  of  nervous  influence.  Hence,  those  who  are  ad- 
vocates for  fever  being  a something  that  pervades  the 
whole  system,  say  you  cannot  refer  it  to  any  one  fixed 
seat;  and,  on  the  other  hand,  those  who  have  taken  up 
the  notion  of  fever  being1  located  either  in  one  organ  or 
in  another,  seldom  or  never  fail,  in  post-mortem  examina- 
tions, to  find  proofs  of  their  own  opinions;  for,  as  no  organ 
escapes  disease,  that  w'hich  is  sought  for  will  be  found, 
whether  the  opinion  of  the  author  lead  him  to  anticipate 
‘cerebritis,’  ‘ gastro-enteritis,’  or  ‘pulmonic  congestion.’” 
And  I will  add,  “disease  of  the  liver.”  One  of  the  first 
compilers  of  the  day,  Professor  Dunglison,  remarks  ; 
“ There  is  a great  diversity  in  the  relative  degree  to 
which  the  local  affection  extends.  Sometimes,  the  brain 
and  stomach  seem  to  be  almost  exclusively  affected  ; in 
other  cases,  the  spleen,  intestines,  and  lungs,  and,  in 
others,  the  liver. 

“ Such  are  the  main  appearances  met  with  in  those 
who  have  died  of  remittent  fever;  but  it  is  obvious  they 
must  differ  almost  ad  infinitum.  In  a disease  attended 
with  so  much  irregularity  of  the  functions  of  innervation 
and  circulation,  and  implicating  the  general  system,  there 
is  scarcely  an  organ,  which  may  not  give  evidences  of 
hypersemia,  if  not  of  active  inflammation.”  These  I 
consider  sensible  and  judicious  remarks;  but  after  ex- 
pressing himself  in  this  manner,  the  professor  is  incom- 
patible with  himself  in  the  following,  which  I take  from 
his  work  on  the  practice  of  medicine.  I allude  here  par- 


244 


REMITTENT  FEVER— PATHOLOGY. 


ticularly  to  the  “ distinctive  differences.”  But  to  the 
extract : “ Where  such  numerous  opportunities  exist  an- 
nually, in  the  southern  and  western  portions  of  this  coun- 
try, for  investigating  the  anatomical  characters  of  our 
remittent  fevers,  it  is  to  be  regretted,  that  they  are  so 
rarely  embraced.  A fine  field  is  afforded  for  the  enter- 
prising pathologist;  and  we  doubt  not  that,  if  it  were  cul- 
tivated, distinctive  differences,  analogous,  perhaps,  to 
those  pointed  out  by  Dr.  Stewardson,  might  be  disco- 
vered, which  would  shed  light  on  the  pathological  cha- 
racters or  accompaniments  of  this  interesting  malady.” 
And  here,  I would  ask,  what  were  the  pathological  con- 
ditions found  by  Dr.  Stewardson?  Was  it  any  one  dis- 
tinctive pathological  condition  uniformly?  and  did  this 
consist  in  the  “ bronze”  color  of  the  liver?  If  I mistake 
not,  Dr.  Stewardson  found  pathological  lesions  in  several 
parts  or  organs.  According  to  Professor  Dunglison,  he 
found  “ lesions  of  the  spleen  and  liver  in  every  case,  and 
development  of  the  glands  of  Brunner  in  the  duodenum; 
and  he  considers,  that  their  frequent  enlargement  and 
uniform  distinctness,  constitute  a striking  peculiarity  of 
the  disease : the  stomach  likewise  was  very  frequently 
inflamed.  In  the  cases  observed  by  him,  the  essential 
anatomical  characteristic  of  the  disease  appeared  to  be 
the  morbid  condition  of  the  liver,  which  was  found  to  be 
flabby,  of  a bronze  color — the  two  substances  blended  to- 
gether so  as  to  be  scarcely  distinguishable ; the  spleen 
wras  much  enlarged  and  softened.”  Dr.  Stewardson  also 
says : “ In  most  of  the  cases,  the  liver  is  described  as 
being  of  the  color  of  bronze,  or  a mixture  of  bronze  and 
olive;  in  one,  as  a dull  lead  color  externally,  internally 
bronzed  with  a reddish  shade  ; in  another,  as  between  a 
brown  and  an  olive,  the  latter  predominating  ; and  finally, 
as  a pale,  slightly  greenish  lead  color,  with  a tinge  of 
brown  in  one  instance.”  Dr.  Gerhard  examined  two 


REMITTENT  FEV ER— PATHOLOGY. 


245 


cases  in  the  Pennsylvania  Hospital  in  1834 ; and  Dr. 
Stewardson  seven,  in  1838,  ’39,  and  ’40 ; and  the  ap- 
pearances, on  post-mortem  examinations,  seem  to  have 
been  analogous.  It  appears  that  the  substance  of  the 
liver  was  generally  somewhat  softened.  In  all  the  cases 
examined  by  these  two  gentlemen,  the  spleen  was  soft- 
ened and  enlarged,  and  generally  to  a great  degree. 
“ In  one  of  Dr.  Gerhard’s  cases  it  was  of  a dark  blue 
color ; in  the  other  it  was  very  black,  and  of  a pulpy  con- 
sistence. In  three  of  Dr.  Stewardson’s  cases,  where  the 
measurements  are  given,  it  was  about  seven  inches  long, 
by  from  four  to  five  broad ; and  in  three  others,  the  lowest 
decree  of  enlarcement  is  stated  at  from  four  to  five  times 

o o 

its  natural  size.  The  softening  also  w~as  great,  amount- 
ing generally  to  pulpiness,  and,  as  the  color  was  dark, 
the  aspect  of  the  organ  was  frequently  very  much  that  of 
a sack  containing  clotted,  venous  blood.  The  mesenteric 
glands  are  free  from  disease.”*  Professor  Bartlett  says, 
“ The  mucous  membrane  of  the  stomach  is  very  gene- 
rally, if  not  always,  more  or  less  changed  from  a healthy 
condition  in  remittent  fever.  In  five  of  six  cases,  where 
it  was  particularly  examined  by  Dr.  Stewardson,  evident 
traces  of  previous  inflammation  were  present.  These 
traces  consisted  of  mammelonation,  and  changes  in  the 
thickness,  consistence,  and  color  of  the  membrane,  va- 
riously combined  in  different  cases.  Similar  appear- 
ances were  found  in  the  two  cases  described  by  Dr.  Ger- 
hard. 

“ The  mucous  membrane,  both  of  the  small  and  large 
intestines,  is  generally  free  from  any  considerable  altera- 
tion, only  such  accidental  lesions  being  found  as  are 
common  after  death  in  most  acute  diseases.  The  ellipti- 

* See  Professor  Elisha  Bartlett’s  work  on  Typhoid  and  Typhus  Fevers ; 
or  the  Amer.  Journ.  Med.  Sci.,  April  1841. 


246 


REMITTENT  FEVER— PATHOLOGY. 


cal  plates  have  been  found  uniformly  healthy.  It  is 
worthy  of  remark,  that  in  all  the  six  cases  examined  by 
Dr.  Stewardson,  in  which  the  duodenum  was  particu- 
larly noticed,  the  mucous  follicles,  or  glands  of  Brunner, 
were  very  distinct  and  prominent.”  Professor  Bartlett 
also  remarks,  that,  “ Of  the  organs  contained  within  the 
cavity  of  the  chest,  * * they  seem  very  rarely 

to  be  the  seat  of  any  considerable  lesion,  in  remittent 
fever,”  and  that  “ neither  the  brain  nor  its  membranes 
have  been  found  to  be  the  seat  of  any  peculiar  or  con- 
stant lesion.”  Dr.  Power,  of  Baltimore,  on  the  post- 
mortem examination  of  three  cases,  corroborates  the 
observations  of  Dr.  Stewardson.  Dr.  Moses,  of  New 
York,  examined  one  case  which  corroborates  the  above. 
Dr.  Richardson  reports  some  cases  that  occurred  in  the 
New  York  Hospital,  in  which  there  were  enlargement, 
and,  in  some  instances,  ulceration  of  Ptyer's  glands. 
This  is  at  variance  with  the  remark  of  Professor  Bartlett, 
above  noticed,  in  alluding  to  the  cases  examined  by  Dr. 
Stewardson.  A question  might  arise  here  as  to  what 
relationship  there  is  between  this  form  of  remittent  fever, 
or  rather  this  complication,  and  typhoid  fever.  It  is  said 
that  follicular  gastro-enteritis  is  notoriously  of  common 
occurrence  in  the  bilious  remittent  fevers  of  New  York. 

More  recently,  the  post-mortem  examinations  of  Drs. 
Anderson  and  Frick,  in  the  Baltimore  Almshouse  and 
Infirmary,  revealed  the  following  : — 

“ Brain. — This  organ  was  examined  in  seven  out  of 
the  ten  cases,  and  in  all  of  them,  either  its  membranes 
or  its  substance  was  injected,  and  in  two  of  them  there 
was  moderate  effusion  in  the  cavity  of  the  arachnoid. 

“ Lungs — In  one-half  of  the  cases,  the  lungs  are  de- 
scribed as  healthy,  and  in  the  other  half  there  was  more 
or  less  intense  redness  of  the  bronchia,  and,  in  one  case, 
of  the  larynx.  But  this  condition  does  not  seem  to  have 


REMITTENT  FEVER— PATHOLOGY. 


247 


been  accompanied  with  cough  during  life,  and  its  in- 
flammatory nature  may,  therefore,  well  be  doubted. 

“ Heart. — The  heart  was  examined  in  nine  cases,  and 
in  all  of  them,  its  muscular  tissue  was  found  to  be  more 
or  less  softened.  The  only  one  in  which  this  condition 
was  not  remarkable,  also  presented  large  fibrinous  con- 
cretions in  both  ventricles.  The  patient  had  been  ‘ very 
delirious,’  and  some  portions  of  his  pia  mater  were  found 
‘infiltrated  with  a turbid,  milky  serum.’ 

“ Stomach  and  Intestines. — The  stomach  generally 
contained  from  two  to  four  ounces  of  a dirty  yellow  fluid. 
The  mucous  membrane  was  found  to  be  injected  in  seven 
out  of  the  nine  cases,  in  which  it  wTas  examined,  and  in 
three  of  them  intensely  so.  In  five  cases  it  was  softened 
near  the  cardiac  extremity,  and  in  four  near  the  pylorus, 
where  also  it  was  for  the  most  part  grayish,  thickened 
and  mammelated.  In  every  instance,  Brunner’s  glands 
were  unusually  developed,  and  in  three  cases  to  a remark- 
able degree.  The  glands  of  Peyer  were  constantly 
healthy,  but  generally  visible. 

“ Spleen. — In  all  the  cases,  without  exception,  the 
spleen  was  very  much  enlarged,  being  from  two  to  six 
times  larger  than  natural.  In  one  instance,  it  weighed 
three  pounds.  In  nine  out  of  ten  cases,  it  was  very  soft 
or  puffy,  and  of  a bluish  black  color. 

“ Liver. — The  size  of  the  liver  was  noted  in  nine  cases, 
in  all  of  which  it  was  unnaturally  large.  Its  consistence 
was  very  much  diminished  in  ten  cases,  in  eight  of 
wThich  the  right  lobe  was  the  principal  seat  of  the  altera- 
tion; in  one  the  left  lobe  was  chiefly  affected,  and  in  the 
remaining  one  the  whole  organ  was  softened.  In  all,  the 
color  of  the  liver  was  either  bronzed,  or  like  that  of  slate; 
the  surface  of  a section  was  polished,  or  shining  ; and  in 
every  instance  but  one  the  different  colors  of  its  compo- 
nent parts  could  not  be  distinguished.  In  seven  out  of 


248 


REMITTENT  FEVER— PATHOLOGY. 


eight  cases,  in  which  the  state  of  the  gall-bladder  was 
recorded,  this  receptacle  was  distended  with  thick,  grum- 
ous  bile,  resembling  molasses.  In  the  eight  cases,  it 
was  moderately  distended  with  straw-colored  bile. 

“From  this  summary  we  may  now  conclude  that  the 
cases  of  remittent  fever  under  examination  presented  the 
following  lesions  uniformly;  to  wit:  1st.  Congestion  of 
the  brain  ; 2d.  Softening  of  the  heart;  3d.  Softening  of 
the  mucous  membrane  of  the  stomach;  4th.  Softening 
of  the  spleen,  with  enlargement ; 5th.  Softening  of  the 
liver,  with  enlargement,  and  a bronzed  or  slate-like  hue 
of  that  organ,  and  distension  of  the  gall-bladder,  with  in- 
spissated bile.”  The  11th  and  12th  cases  are  not  in- 
cluded in  this  summary,  “ the  one  appearing  to  be  a case 
of  pneumonia,  occurring  some  time  after  an  attack  of  in- 
termittent, or  possibly  remittent  fever,  and  the  other  a 
case  of  dysentery,  coming  on  during  convalescence  from 
remittent  fever.” 

“ Of  all  these  morbid  alterations,  the  only  one  peculiar 
to  remittent  fever  is  that  of  the  liver,  which  was  for  the 
first  time  pointed  out,  and  so  well  described,  by  Dr. 
Stewardson,  and  which  the  present  series  of  cases,  taken 
along  with  those  previously  observed  by  himself  and  by 
Dr.  Swett,  justifies  him  in  regarding  as  the  anatomical 
characteristic  of  the  disease.  But  it  does  not  stand  alone. 
The  spleen,  the  stomach,  the  heart,  and  the  brain,  are  all 
diseased;  and,  what  is  still  more  remarkable,  they,  with 
the  liver,  have  one  lesion  in  common,  viz.,  softening. 
The  hepatic  alteration  is  evidently  not  that  to  which  the 
symptoms  of  remittent  fever  can  be  referred  as  a cause. 
Our  knowledge  of  the  phenomena  attending  inflamma- 
tion of  the  liver  on  the  one  hand,  and  of  the  close  analogy 
existing  between  remittent  fever  and  intermittent  fever 
(in  which  the  liver  is  unchanged)  on  the  other,  forbids 
such  a supposition.  The  bronzed  and  slaty  hues  of  this 


REMITTENT  FEVER— PATHOLOGY. 


249 


organ  are  pretty  certainly  due  to  the  congestion  of  its 
biliary  ducts  with  bile,  and  of  its  veins  with  blood,  so 
that  its  softening  only  remains  to  be  studied,  as  well  in 
its  origin  as  in  its  effects.  But  this  softening,  as  already 
remarked,  is  common  to  it  and  to  several  other  organs. 
The  question  is  therefore  enlarged,  and  we  have  next  to 
inquire  towdiat  ought  the  diminished  consistence  of  these 
several  organs  to  be  attributed  ? Here  are  two  parenchy- 
matous structures  (the  liver  and  spleen),  a mucous  mem- 
brane (of  the  stomach),  and  a muscle  (the  heart),  softened 
in  the  same  disease.  It  will  not  be  pretended  that  the 
change  is  due  to  inflammation  ; for  the  symptoms  of  this 
condition,  as  it  occurs  in  the  several  organs,  are  wanting. 
Is  it  owing  to  a cause  like  that  which  produces  softening 
in  typhus  fever,  and  in  all  diseases  of  a typhoid  type? 
In  one  word,  is  it  due  to  an  alteration  of  the  blood  ?”* 
While  writing  on  the  subject  of  the  pathology  post- 
mortem, examinations  of  remittent  fever,  I inadvertently 
neglected  to  refer  to  the  facts  and  remarks  of  Dr.  Boling, 
in  relation  to  post-mortem  appearances,  which  I consider 
worth  more  to  the  practitioner  than  all  others  heretofore 
made  on  this  subject,  and  though  the  extract  is  long,  I con- 
sider it  worthv  of  being  inserted  entire. t It  is  as  follows : — 
“ Post-mortem  appearances. — There  is  some  probability 
that  these  differ  a good  deal  in  different  seasons,  and  in 
different  localities,  as  considerable  diversity  exists  in  the 
descriptions  of  authors. 

“ In  regard  to  the  lungs,  heart,  kidneys,  and  bladder, 
there  is  nothing  at  all  in  the  post-mortem  appearances  at 
all  characteristic  or  peculiar.  These  organs,  as  in  all 
other  acute  diseases,  may  all  be  at  times  the  seats  of  ac- 
cidental complications,  and  wrhen  so,  of  course  give  post- 

* Alfred  Stille,  M.  D.,  Amer.  Journ.  Med.  Sci.,  April,  1846. 
f This  extract  was  assigned  a place  here,  after  this  chapter  on  remit- 
tent fever  had  been  written. 

17 


250 


REMITTENT  FEVER— PATHOLOGY. 


mortem  evidences  of  the  same.  The  same  may  be  said 
measurably  of  the  brain,  which,  although  at  times  affected 
with  inflammation  and  congestion,  and  presenting  the 
post-mortem  evidences  of  these  conditions,  is  nevertheless 
frequently  found  in  an  entirely  healthy  state.  In  all  the 
cases  of  the  comatose  remittent  that  I have  examined, 
great  congestion  of  the  brain  and  membranes  has  been 
present.  In  that  shade  of  the  comatose  remittent  last 
described,  I should  not  expect  to  find  these  conditions 
present.  But  I have  never  examined  a case,  none  of  the 
kind  having  ever  proved  fatal  in  my  practice. 

“The  stomach  I have  invariably  found  presenting  de- 
cided traces  of  recent  inflammation,  and  there  is  no  other 
organ  in  regard  to  the  post-mortem  appearances  of  which 
authors  have  been  so  unanimous.  We  are  told  by  Prin- 
gle, that  Thomas  Bartholinus,  on  finding  the  stomach  and 
duodenum  always  inflamed  and  mortified , in  a malignant 
remittent  fever  that  prevailed  in  Copenhagen  in  1652, 
assigned  these  parts  as  the  principal  seat  of  all  malignant 
fevers. 

“The  intestines  also  present  frequent  marks  of  inflam- 
mation, though  not  so  universally  as  the  stomach.  The 
duodenum  most  generally  suffer  from  a continuation  of 
disease  from  the  stomach,  and  the  mucous  follicles  or 
glands  of  Brunner  of  this  part,  as  first  noticed  in  this 
disease  by  Dr.  Stewardson,  will  generally,  though  not 
invariably,  be  found  enlarged.  The  jejunum  is,  perhaps, 
less  frequently  diseased  than  any  other  part  of  the  intes- 
tinal canal,  though  occasionally  it  will  be  found  to  contain 
patches  of  ramiform  and  capilliform  injection.  The 
ilium,  more  frequently  -than  any  portion  of  the  intestinal 
canal,  the  stomach,  and,  perhaps,  duodenum  alone  ex- 
cepted, presents  traces  of  inflammation,  in  all  cases 
increasing  in  intensity  as  we  approach  the  ileo-csecal 
valve.  The  glands  of  Peyer,  to  which  attention  has 


REMITTENT  FEVER— PATHOLOGY. 


251 


been  more  particularly  directed  of  late,  in  consequence 
of  their  diseased  condition  being  considered  the  anatomi- 
cal characteristic  of  typhoid  fever,  have,  by  different 
observers,  been  found  in  different  conditions.  They  are 
stated  by  Dr.  Bartlett  to  ‘ have  been  found  uniformly 
healthy.’  He  has  here  reference  merely,  however,  to 
cases  examined  by  Dr.  Gerhard  and  Dr.  Stewardson,  in 
the  Pennsylvania  Hospital  at  different  times.  In  Sep- 
tember, 1843,  I examined  a case  of  remittent  fever,  an 
originally  mild  one,  but  which,  by  neglect  and  misman- 
agement, was  permitted  to  assume  a grave  form.  The 
case  w’as  unusually  protracted,  commencing  August  7th, 
and  terminating  fatally  on  the  17th  of  September.  In 
my  notes  of  the  post-mortem  examination,  which  was 
made  three  hours  after  death,  it  is  stated  that  ‘the  small 
intestines  presented  slight  traces  of  inflammation  through- 
out nearly  their  whole  extent,  increasing  in  intensity  in 
descending  to  the  ileo-crecal  valve.  The  elliptic  plates 
were  of  a much  darker  color  than  the  rest  of  the  mucous 
membrane,  granular  to  the  eye  and  touch,  the  margins 
well-defined  and  slightly  elevated,  and  some  of  them  pre- 
senting distinct  traces  of  ulceration.  These  characters 
were  more  distinct  just  above  the  ileo-caecal  valve,  and 
were  gradually  lost  in  ascending  the  intestine.  Mesen- 
teric glands  slightly  enlarged.’  In  another  case,  of  a 
negro  girl,  terminating  fatally  on  the  ninth  day,  August, 
1844,  examination  five  hours  after  death,  it  is  stated,  that 
there  was  ‘ considerable  inflammation  of  the  small  intes- 
tines ; elliptic  plates  of  ilium  elevated,  granular  to  the 
touch,  and  darker  than  the  rest  of  the  canal.  Solitary- 
glands  much  enlarged,  many  of  them  ulcerated  ; the 
margins  hard,  and  the  edges  of  the  ulcers  abrupt;  the 
ulceration  in  some  places  extending  through  all  but  the 
peritoneal  coat.  Mesenteric  glands  a good  deal  enlarged.’ 
In  this  last  case  diarrhoea  existed,  in  the  former  not. 


252 


REMITTENT  FEVER— PATHOLOGY. 


These  are  the  only  instances  in  which  I have  observed 
any  morbid  alteration  of  the  elliptic  plates.  They  are, 
however,  almost  the  only  cases  terminating  fatally  at  so 
late  a period,  that  I have  been  permitted  to  examine.  The 
result  of  these  has  induced  me  to  think  it  probable,  that 
in  many  protracted  cases  some  alteration  of  the  glands 
of  Peyer  and  Brunner  will  be  found,  and  at  an  earlier 
period  in  those  which  have  been  attended  with  diarrhoea. 

“The  spleen  is,  in  a majority  of  cases,  found  enlarged, 
dark,  and  somewhat  softened ; and,  occasionally,  this 
alteration  is  so  great  that  the  interior  of  the  organ  resem- 
bles a mass  of  black,  clotted  blood,  contained  in  a coarse, 
cellular  mesh  ; and  so  pulpy  as  readily  to  yield  to  but  the 
slightest  pressure.  This  alteration  of  the  spleen  is,  how- 
ever, more  a consequence  of  what  may  be  called  the 
latent  action  of  malaria,  than  a necessary  accompaniment 
of  remittent  fever;  as,  in  no  instance,  have  I ever  found 
enlargement  of  the  organ  during  life,  or  any  morbid  ap- 
pearance after  death,  in  a first  attack  of  remittent  fever, 
in  a person  who  had  not  previously  resided  some  con- 
siderable time  in  a malarious  region.  In  all  cases,  how'- 
ever,  where  any  enlargement  exists  prior  to  the  attack,  a 
considerable  augmentation  almost  invariably  takes  place 
before  the  patient  dies.  In  almost  every  case,  perhaps 
every  one,  where  any  enlargement  of  the  spleen  is  present 
during  an  attack  of  remittent  fever,  or  after  death  from 
the  same,  on  inquiry  we  may  be  satisfied  of  its  having 
existed  prior  to  the  attack. 

“The  liver  is  the  organ  to  which,  from  his  preparatory 
instruction,  the  young  physician,  commencing  practice  in 
the  South,  will  at  first  have  his  attention  more  especially 
directed,  and  will  be  governed  much  in  the  application 
of  his  remedial  agents  by  its  morbid  or  supposed  morbid 
condition.  A few  authors  speak  of  having  found  it  but 
slightly  altered,  but  by  a large  number  of  those  whose 


REMITTENT  FEVER— PATHOLOGY. 


253 


authority  has  been  most  influential,  we  are  led  to  expect 
manifest  and  palpable  changes.  In  the  one  case  which 
seems  to  have  determined  Dr.  James  Johnson,  in  the  re- 
jection of  the  Peruvian  bark  as  a principal  agent,  and  to 
have  decided  him  in  regard  to  his  subsequent  practice, 
blood-letting,  and  calomel,  the  liver  was  found  ‘so  gorged, 
as  it  were,  with  blood,  that  it  actually  fell  to  pieces  on 
handling  it.’  Although  we  are  not  taught,  in  all  cases, 
to  expect  to  find  the  alteration  so  extreme  as  in  this  in- 
stance, yet,  in  a less  marked  degree,  this  is  the  character 
of  what  we  are  taught  to  expect  in  almost  all.  I had  so 
strongly  made  up  my  mind  in  regard  to  the  existence  of 
this  state  of  the  liver,  in  the  commencement  of  my  prac- 
tice, that  it  was  a matter  of  great  surprise  to  me  never  to 
find  well-marked  fullness  or  tenderness  of  the  right  hy- 
pochondriac region.  This  surprise  was  far  exceeded, 
however,  by  that  which  I felt  on  finding  no  traces  of  en- 
gorgement of  the  liver  present,  in  my  first  post-mortem 
examination.  I looked  upon  this  case,  however,  as  an 
exception ; but  all  my  future  examinations  revealed  the 
same  state  of  things. 

“ In  no  case,  that  I have  ever  treated,  have  I found, 
during  life,  any  evidence  of  affection  of  the  liver  more 
than  that  functional  derangement  partaken  by  it  in  com- 
mon with  every  other  organ  during  the  state  of  febrile 
excitement ; and  I will  venture  to  say  that,  in  nearly 
every  case,  this  functional  disorder  will  be  as  palpable 
and  as  well  marked  in  the  kidneys  as  in  the  liver.  I will 
also  remark,  en  passant,  that,  in  a practice  of  nine  years 
in  the  South,  I have  never  had  under  treatment  one 
single  case  of  well-marked  and  unequivocal  hepatitis, 
acute  or  chronic. 

“Disappointed  in  not  finding  the  changes  in  the  liver 
which  I had  been  led  to  expect,  and  the  morbid  altera- 
tions, if  any,  being  so  different  from  what  others  had 


254 


REMITTENT  FEVER— PATHOLOGY. 


described,  and  less  easy  of  appreciation,  particularly  to 
one  not  accustomed  to  frequent  post-mortem  examinations , 
I was  led  to  believe  that  lesions  of  this  organ  were  less 
frequently  found  after  death  than  of  almost  any  other. 

“In  an  article  published  by  Dr.  Stewardson,  in  the 
American  Journal  of  Medical  Sciences  for  April,  1841,  in 
which,  among  certain  other  post-mortem  appearances, 
which  he  is  disposed  to  think  somewhat  peculiar  to  re- 
mittent fever,  he  describes  an  appearance  of  the  liver  not 
heretofore  particularly  noticed,  and,  from  the  result  of  a 
good  many  examinations,  arrives  at  the  conclusion,  that 
it  is  probably  ‘the  anatomical  characteristic  of  that  dis- 
ease.’ This  alteration  is  described  as  consisting,  in  most 
cases,  in  a flabby  state  of  the  organ,  the  color  externally 
being  of  a bronze,  or  a mixture  of  bronze  and  olive,  and 
internally  of  an  olive,  with  an  entire  extinction  of  the 
natural  reddish-brown.  It  appears  to  have  been  generally 
of  the  natural  size,  and  ‘ the  two  substances  so  blended 
as  to  be  scarcely  distinguishable.’  The  appearances 
described  by  Dr.  Stewardson  have  since  been  found  by 
others,  and  are  particularly  noticed  by  Dr.  Swett,  in  the 
American  Journal  of  Medical  Sciences  for  January,  1845. 
I have  given  above  what,  on  a pretty  close  examination 
of  Dr.  Stewardson’s  cases,  seems  to  me  to  have  been  the 
appearance  of  a large  number  of  them,  but  still  the 
description  of  the  ‘ anatomical  characteristic ,’  as  given  by 
himself,  differs  materially  from  this  in  some  of  the  others. 
For  instance,  we  have  one  described  as  being  ‘ of  a pale, 
slightly  greenish  lead  color,’  one  ‘ of  a dull  bronze,’  and 
in  another,  the  ‘ surface  of  a dull  lead  color.’  In  the  cases 
of  Dr.  Swett  there  is  also  found  this  diversity  of  appear- 
ance in  the  color  of  the  liver.  One  case  ‘presented  ex- 
ternally a slate  color,  which,  when  placed  in  a proper 
light,  gave  a bronze  tint.’  Another  was  of  ‘ a pale  slate 


REMITTENT  FEVER— PATHOLOGY. 


255 


color,  and  in  many  parts  a bronze  tint  was  perceptible,’ 
and  another  ‘ externally  was  of  a bronzed  appearance.’ 

“ On  the  appearance  of  the  above  article  of  Dr.  Stew- 
ardson,  my  attention  was  again  directed  to  the  liver,  but 
I have  been  able  in  but  a very  few  instances  to  find  any 
alteration  ; and  even  where  such  did  exist,  a slight  exer- 
tion of  the  imagination  would  have,  perhaps,  been  neces- 
sary to  trace  a close  resemblance  between  them  and  the 
descriptions  of  Dr.  Stewardson.  Indeed,  in  a large  pro- 
portion of  cases,  the  organ,  so  far  as  I am  capable  of 
judging,  was  entirely  healthy.  Where  it  was  otherwise, 
the  concave  surface  of  the  organ  was  of  what  appeared  to 
me  an  uniformly  bluish-slate  color,  extending  to  about 
the  depth  of  a quarter  of  an  inch  ; the  line  of  demarka- 
tion  between  this,  and  that  portion  which  presented  a 
natural  appearance,  being  well  defined.  In  every  case 
in  which  I have  observed  this  appearance,  with  one  ex- 
ception, it  was  confined  to  the  concave  surface,  the  convex 
surface  and  the  interior  being  entirely  healthy.  The 
exception  was  in  a case  which,  in  the  beginning,  presented 
the  symptoms  of  what  is  generally  denominated  vermin- 
ous or  infantile  remittent  fever.  In  its  progress  peritoni- 
tis supervened,  and  the  patient  died  about  the  beginning 
of  the  fourth  week.  On  a post-mortem  examination,  a 
considerable  quantity  of  serum  and  coagulable  lymph 
was  found  in  the  abdomen,  and  both  surfaces  of  the  liver 
were  found  uniformly  of  the  color  above  alluded  to,  the 
interior  of  the  organ  being  apparently  healthy.  This 
appearance  of  the  liver  I have  observed  in  an  equal  pro- 
portion of  cases,  I think,  in  the  post-mortem  examinations 
of  patients  dying  from  other  diseases ; though  I have  no 
recollection  at  this  time  of  having  observed  it  in  any 
case,  in  which  the  patient  had  not  labored  under  an  attack 
of  remittent  or  intermittent  fever,  within  a month  or  six 


256 


REMITTENT  FEVER— PATHOLOGY. 


weeks  previous  to  the  commencement  of  the  disease 
causing  death. 

“ In  conclusion,  I would  observe,  that  ail  my  remarks 
in  regard  to  the  symptoms,  treatment,  and  post-mortem 
appearances  of  remittent  fever,  are  made  with  reference 
to  the  disease  as  it  prevails  here  in  Montgomery,  and  in 
its  immediate  vicinity,  for,  as  I have  before  observed, 
these  may  all  vary  in  different  localities.” 

The  Blood. — Dr.  Stewardson  suggests  “that an  altered 
condition  of  the  blood,  combined,  perhaps,  with  some 
softening  of  the  tissue  of  the  lungs,  may  have  given  rise 
to  an  effusion  of  bloody  serum,  noticed  by  him  ; he  also 
notices  the  flabbiness  of  the  heart,  in  some  instances,  and 
the  absence  of  firm,  fibrinous  coagula  in  all,  and  remarks 
that  it  is  perfectly  evident  that  the  blood,  in  this  disease,  is 
the  seat  of  morbid  changes  which  deserve  attention;  and, 
again,  that  to  the  state  of  this  fluid  we  must  no  doubt 
look,  in  part,  for  an  explanation  of  the  fatal  termination 
in  some  cases.”  Professor  Dunglison  remarks,  that,  “As 
in  other  febrile  and  inflammatory  diseases,  the  blood  be- 
comes modified  in  its  character;  and  the  view  has  been 
maintained,  that  remittents  originate  in  a disorganized 
state  of  this  fluid,  as  indicated  by  its  black  crimson  color, 
which  Dr.  Stephens  considers  to  be  owing  to  the  entire 
removal,  or  great  diminution,  of  its  saline  ingredients. 
This  altered  condition  of  the  blood,  he  thinks,  induces  a 
morbid  modification  of  the  action  of  the  solids  as  certainly 
as  fever  is  induced  by  the  injection  of  a putrid  and  poi- 
sonous fluid  directly  into  the  blood-vessels.  The  altered 
condition  of  the  blood  cannot  be  contested ; but  it  may 
admit  of  question,  whether  it  ought  to  be  regarded  as  the 
first  link  in  the  chain  of  phenomena.”  The  result  of  the 
analyses  of  the  blood  by  Dr.  Charles  Frick,  is  at  variance 
with  the  opinions  of  Dr.  Stephens.  The  reader  will 
please  refer  to  the  first  five  cases  in  the  table  at  page 


REMITTENT  FEVER— PATHOLOGY. 


257 


66,  or  the  American  Journal  of  the  Medical  Sciences, 
January,  1848,  page  30. 

In  post-mortem  examinations,  pathologists  have  been 
too  exclusively  seeking  to  find  some  uniform  local  lesion, 
as  characteristic  or  pathognomonic  of  remittent  fever, 
and  other  diseases,  to  the  neglect  of  the  altered  condition 
of  the  blood.  Microscopic  examinations  and  chemical 
analyses  might  be  of  much  service  in  this  department; 
and  be  really  of  vastly  more  importance  than  the  dispo- 
sition of  some  to  concentrate  the  mind  towards  the  mor- 
bid condition,  or  bronze  color,  of  the  liver.  The  morbid 
condition  of  the  nervous  system,  both  prior  to  and  after 
death,  is  also  too  much  overlooked,  especially  by  our  hy- 
perborean brothers,  and  also  by  many  in  the  South. 
Though  many  of  the  southern  practitioners  look  to  the 
implication  or  morbid  affection  of  the  nervous  system  du- 
ring life,  they  also  manifest  too  much  apathy  with  regard 
to  its  pathological  lesions  in  the  dead  subject.  The  want 
of  success  heretofore  attending  the  search  after  patholo- 
gical conditions  of  the  nervous  system  after  death,  no 
doubt,  deters  many  from  venturing  in  this  field  of  patho- 
logical research. 

I consider  it  a curse,  rather  than  a blessing,  that  this 
“ bronze ” color  of  the  liver  has  attracted  attention  in  the 
last  few  years.  Just  as  the  profession  is  about  emerging 
from  an  erroneous  theory,  and  corresponding  improper 
treatment,  it  is  to  be  feared  that  this  concentration  of  at- 
tention towards  the  liver  will  tend  to  perpetuate  the  in- 
judicious and  indiscriminate  use  of  calomel  and  blue 
mass.  At  present,  it  would  indeed  seem,  that,  while 
southern  practitioners  are  eminently  successful  in  the 
treatment  of  remittent  fever,  our  northern  brethren  are 
plodding  along  after  the  “ bronze  color  of  the  liver,”  re- 
lying or  expecting  much  from  their  numerical  statistics. 
But,  after  all,  what  therapeutic  indication  does  the  bronze, 


258 


REMITTENT  FEVER— PATHOLOGY. 


olive,  or  slate  color  of  the  liver  furnish  to  practitioners? 
If  it  should  be  found  to  exist  in  every  fatal  case  of  remit- 
tent fever,  and  in  no  other  disease,  it  might  be  considered 
as  characteristic  of  this  disease  (and  I suppose  that  the 
most  ardent  “ bronze  liver ” hunters  and  advocates  claim 
nothing  more;  but  even  this  might  be  of  interest  in  a 
medico-legal  point  of  view,  though  rarely),  and  also  con- 
tribute to  feed  the  inclinations  of  those  who  manifest  a 
sort  of  pride  in  necroscopic  searches,  which  are  too  often 
erroneous,  or  lead  to  wrong  conclusions,  in  accordance 
with  preconceived  opinions.  I wish  it  to  be  understood, 
that  I do  not  object  to  post-mortem  examinations — far 
from  it;  as  by  these  investigations,  if  properly  directed, 
much  light  is  thrown  on  the  subject  of  medicine.  But 
I do  not  know  that  the  bronze  color  of  the  liver  has,  or 
ever  will  offer  any  therapeutic  indication  whatever.  In 
typhoid  fever,  the  affection  of  Peyer’s  glands  and  the 
lower  portion  of  the  ileum,  furnish  very  important  thera- 
peutic indications.  But  it  may  be  said  that  this  uniform 
color  of  the  liver  may  be  of  importance  in  diagnosis — 
in  establishing  a characteristic  difference  in  remittent, 
from  typhoid,  typhus,  and  other  fevers.  In  the  cases  that 
we  have  noticed,  examined  by  Dr.  Stewardson  and  others, 
the  liver,  however,  was  not  uniformly  of  the  same  color. 
Though  Dr.  Stewardson,  in  most  cases,  observed  a bronze 
or  olive  color  of  the  liver,  or  a mixture  of  these,  yet,  in 
others,  he  speaks  of  “ a pale,  slightly  greenish  lead  color, 
with  a tinge  of  brown  in  one  instance.”  In  those  exa- 
mined by  Drs.  Anderson  and  Frick,  “ In  all,  the  color  of 
the  liver  was  either  bronzed  or  like  that  of  slate;  the 
surface  of  a section  was  polished  and  shining ; and,  in 
every  instance  but  one,  the  different  colors  of  its  compo- 
nent parts  could  not  be  distinguished.”  So  we  see  that 
there  is  not  uniformity  in  the  color  of  the  liver — not  even 
in  all  the  cases  examined  by  Dr.  Stewardson  himself. 


REMITTENT  FEVER— MILD  FORM,  TREATMENT.  259 


But,  having  already  extended  these  remarks  beyond  what 
was  intended,  in  relation  to  this  matter,  which  should 
scarcely  attract  the  attention  of  physicians,  I will  leave 
the  further  analysis  of  these  cases  to  those  who  feel  more 
interested  in  them  ; being  strongly  inclined,  for  my  own 
part,  from  the  very  nature  of  remittent  fever,  to  believe 
it  probable  that  this  bronze  liver  notion  will  have  its  day 
(like  Broussais’  gastro-enterite , and  other  popular  notions), 
and  be  regarded  by  subsequent  generations  as  a relic, 
or  prejudice,  resulting  from  the  misguided  attention 
or  ignorance  of  the  present  age.  But,  before  quitting 
this  subject,  I must  be  permitted  to  remark,  that  this 
concentration  of  attention  to  the  liver  has  a bad  effect 
in  several  ways.  First,  by  inducing  neglect  of  the  most 
important  considerations — the  condition  of  the  nervous 
system,  and  the  blood,  both  prior  to  and  after  death. 
And,  secondly,  it  is  to  be  very  much  feared  that  it  will 
perpetuate  the  too  free  and  indiscriminate  use  of  mer- 
curial preparations.  But,  after  these  already  protracted 
remarks,  I must  dismiss  this  part  of  the  subject,  and 
proceed  to  what  I consider  of  vastly  more  importance, 
namely,  the 

TREATMENT  OF  REMITTENT  FEVER. 

1.  Treatment  of  the  Simple  or  Mild  Form. — 
Ordinarily,  this  form  of  remittent  fever  is  very  easily 
managed  or  controlled,  especially  if  the  treatment  be 
commenced  soon  after  the  attack.  When  called  to  a 
case  of  this  kind,  I usually  give,  at  first,  a dose  com- 
posed of 

Quinine  four  to  sis  or  eight  grains ; 

Calomel  eight  to  ten  or  twelve  grains  ; 

Rhubarb  eight  to  ten  or  fifteen  grains. 

To  which  I frequently  add,  if  the  stomach  is  not  irrita- 


260  REMITTENT  FEVER— MILD  FORM,  TREATMENT. 

ble,  two  grains  of  ipecacuanha;  if  irritable,  or  a disposi- 
tion to  nausea,  in  place  of  the  ipecacuanha,  add  about 
one-third  of  a grain  of  morphine ; or,  if  not,  and  the  skin 
is  hot  and  dry,  both  the  ipecacuanha  and  the  morphine 
may  be  added.  In  those  cases,  too,  in  which  the  skin  is 
hot  and  dry,  ten  grains  of  jalap  may  be  added  in  place  of 
the  rhubarb,  as  the  former  is  a much  better  diaphoretic. 
Some  four  or  five  hours  after  this,  the  quinine  should 
be  repeated,  combined  with  four  or  five  grains  of  jalap, 
to  which  two  grains  of  ipecacuanha  may  be  added,  if  the 
stomach  is  not  irritable,  or,  if  it  is,  the  morphine  may 
again  be  added.  After  this,  give  the  quinine  every 
four,  five,  or  six  hours,  according  to  its  influence,  with 
the  addition  of  the  ipecacuanha,  provided  there  is  no 
gastric  irritability,  or  a teaspoonful  of  the  tincture 
of  lobelia  may  be  added  in  place  of  the  ipecacuanha. 
This  plan  generally  soon  produces  warm  diaphoresis  and 
manifest  improvement  in  the  condition  of  the  patient,  and 
convalescence  is  soon  brought  about.  After  twenty-four 
or  thirty-six  hours  from  the  exhibition  of  the  first  dose  of 
medicine,  I sometimes  repeat  a similar  one,  if  the  morbid 
condition  has  not  yielded  considerably.  When  the  dis- 
ease seems  readily  to  yield,  for  this  dose,  in  place  of  the 
calomel,  I add  rhubarb,  rhubarb  and  extract  of  dandelion 
{taraxacum),  or  extract  of  the  white  walnut,  just  sufficient 
in  amount  to  produce  a mild  aperient  effect.  After  this, 
one  or  two  discharges  from  the  bowels  a day  are  suffi- 
cient. Active  purging  should  be  avoided.  If  the  quin- 
ine should  have  a tendency  to  produce  irritation  of  the 
bowels  and  too  frequent  -watery  discharges,  a teaspoonful 
of  paregoric,  or  a little  laudanum  (twenty  or  thirty  drops), 
should  be  combined  with  a dose  of  it,  or  given  alone,  so 
as  to  control  this  condition.  If  there  is  much  febrile  ex- 
citement, and  twelve  or  twenty-four  hours  have  elapsed 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


261 


since  the  exhibition  of  the  first  dose,  a ten-grain  dose  of 
calomel  may  be  added. 

If  the  patient  is  thirsty,  he  should  frequently  be  al- 
lowed to  drink  small  quantities  of  cold  water,  or  he 
ought  to  eat  small  quantities  of  ice,  oft  repeated.  If 
his  skin  is  hot  and  dry,  he  should  occasionally  be 
sponged  all  over  with  cool  or  cold  water.  If  there 
is  determination  to  the  head,  with  headache,  cold  water 
should  be  freely  and  frequently  poured  over  the  head  and 
back  of  the  neck  of  the  patient  till  relief  is  obtained.  If 
there  is  much  restlessness,  with  hot,  dry  skin,  sponging 
the  body  with  cool  or  cold  water,  cold  or  iced  water  to 
drink,  opiates,  and  quinine,  are  the  remedies  for  this  con- 
dition. By  this  means,  the  hot,  dry  skin  is  soon  cooled 
and  covered  with  a moderately  free  perspiration,  the 
restlessness  and  oppression  are  soon  relieved,  and  the  pa- 
tient feels  calm  and  composed,  and,  perhaps,  drops  into  a 
pleasant  and  comfortable  sleep,  and  the  fever,  almost  in- 
variably, immediately  arrested. 

It  is  rarely  necessary  to  resort  to  venesection  in  this 
mild  form.  If,  however,  there  should  be  considerable 
febrile  excitement,  with  determination  to  any  import- 
ant organ,  it  may  be  necessary  to  draw  a moderate  quan- 
tity of  blood, 'especially  if  these  conditions  are  not  easily 
controlled  by  the  means  already  noticed,  or  danger  is  ap- 
prehended from  delay ; and  more  particularly  if  the  pa- 
tient is  of  a full  habit  or  sanguine  temperament.  As 
irritability  of  the  stomach  is  not  often  a troublesome  at- 
tendant in  this  form,  I will  defer  its  further  treatment 
till  I come  to  speak  of  the  second  form,  or  causus. 

The  apartment  of  the  patient  should  be  -well  venti- 
lated, and  made  agreeable  to  him. 

2.  Treatment  of  the  Second  Form,  the  Causus. — 
This  form,  it  would  appear,  of  late  years,  is  most  com- 


262 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


mon  in  the  middle  and  more  northern  portions  of  this 
country,  with  exceptions  now  and  then  in  some  southern 
localities.  It  is  said  to  be  common  in  the  city  of 
Charleston,  after  individuals  go  out  into  the  malarious 
or  neighboring  swampy  regions,  and  return  to  the  city. 
Within  the  last  eight  or  ten  years  the  causus  appears  to 
have  been  less  frequent  than  formerly,  and  pretty  much 
supplanted  by  the  causodes  and  other  forms  of  malarious 
fevers,  in  the  south  and  south-wmstern  States.  And  here 
I will  remark,  that  I do  not  know  that  we  should  consi- 
der the  causodes  as  a less  dangerous  form  than  the  causus, 
but  that  it  is  apparently  less  intense,  the  febrile  and  in- 
flammatory excitement  not  being  so  high;  yet  the  nervous 
system  appears  to  be  more  profoundly  implicated,  more 
depressed,  with  less  power  of  reaction.  In  the  States  of 
Tennessee  and  Kentucky,  and,  perhaps,  in  other  places, 
it  appears  that  the  causus,  in  the  last  few  years,  has  partly 
been  supplanted  by  typhoid  fever;  frequently  and  im- 
properly called  typhus  fever , in  some  localities. 

When  a well-marked  case  of  the  causus  occurs  in  the 
south  and  south-western  States,  it  is  most  apt  to  be  among 
those  of  vigorous  or  sanguine  temperament.  Hence, 
also,  the  greater  liability  of  those  who  have  recently  ar- 
rived from  the  North.  It  seems  quite  clear  that  its  more 
frequent  occurrence  in  the  South,  many  years  ago,  may, 
in  a considerable  degree,  be  accounted  for  by  the  emigra- 
tion from  the  more  northern  portions  of  the  world ; as 
new  emigrants  from  the  North  are  now  more  liable  to  it 
than  the  resident  citizens;  and  this  explanation  will  ap- 
ply to  the  liability,  heretofore,  of  the  British  troops  sta- 
tioned in  intertropical  regions.  Dr.  Cartwright  gives  an 
account  of  this  form  of  remittent  fever,  which  prevailed 
in  an  epidemic  manner,  in  Monroe  county,  Mississippi, 
in  1822.  “ The  disease  was  generally  ushered  in  by  a 

distinct  chill,  which  was  speedily  followed  by  intense 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


263 


heat,  thirst,  and  headache,  and  very  severe  pains  in  the 
loins.  The  anxiety  and  difficulty  of  breathing,  the  deadly 
sickness,  sense  of  weight,  heaviness,  and  pain  in  the  sto- 
mach, increased  as  the  fever  approached  its  acme,  until 
the  suffering  became  intolerable.  The  exacerbations 
generally  occurred  in  the  evening,  and  a considerable  re- 
mission, amounting  in  some  cases  to  a perfect  intermis- 
sion, took  place  on  the  ensuing  morning.  On  the  even- 
ing of  the  second  day  a sudden  and  unexpected  paroxysm, 
more  violent  than  the  first  one,  came  on,  which  was  at- 
tended with  a most  horrid  sensation  of  pain  and  oppres- 
sion of  the  stomach,  accompanied  with  deadly  sickness 
and  continued  vomiting,  but  with  the  ejection  of  very 
little  fluid  of  any  kind.  The  bowels,  during  the  first  and 
second  paroxysms,  were  always  in  a state  of  obstinate 
constipation.  About  noon,  the  third  day,  the  third  par- 
oxysm generally  came  on,”  &c.  &c.  It  is  well  known, 
that,  at  this  time,  Monroe  county  was  a newly  settled 
region  of  country,  the  emigrants  being  principally  from 
a more  northern  region  of  country. 

If  one  who  is  taken  with  the  causus  be  seen  within 
one,  twro,  or  three  days  from  the  time  of  attack,  and  if 
the  reaction  is  very  great,  with  determinations  to  impor- 
tant organs,  it  will  generally  be  advisable  to  take  blood 
from  the  arm  to  the  extent  of  from  twelve  to  twenty-four 
ounces  (from  three  gills  to  a pint  and  a half),  according 
to  the  temperament  and  vigor  of  the  patient,  and  the  vio- 
lence of  the  disease.  After  the  second  or  third  day, 
however,  it  should  be  practiced,  if  at  all,  with  great  cau- 
tion— seldom  being  safe  to  resort  to  it  after  this  period. 
If  there  should  be  still  considerable  arterial  excitement, 
full,  hard  pulse,  hypersemia,  or  determination  to  some  im- 
portant organ,  it  may  still  be  of  service,  guided  by  judg- 
ment and  caution,  lest  prostration  be  induced.  Venesec- 
tion, in  the  early  stages,  has  not  only  a tendency  to  lessen 


264 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


the  febrile  excitement,  but  also  to  relieve  the  great  gastric 
distress,  nausea,  vomiting,  and  irritability  of  the  sto- 
mach, which,  in  many  cases,  is  very  troublesome  and 
obstinate. 

In  the  causodes,  venesection  is  seldom  advisable;  and, 
when  resorted  to,  should  be  practiced  with  judgment  and 
sufficient  caution,  especially  after  the  first  two  days  from 
the  time  of  attack.  Indeed,  blood-letting  may  generally 
be  dispensed  with  in  this  form  or  modification  of  remit- 
tent fever. 

In  the  causus,  soon  after  the  venesection,  or  if  the  ex- 
citement has  not  been  sufficiently  great  to  demand  a 
resort  to  this  means,  I commonly  give  a dose  com- 
posed of 

R.  Sul  pi! . morphine  one-third  to  one-half  a grain  ; 

Sulph.  quinine  eight  to  twelve  grains  ; 

Calomel  eight  to  thirty  grains  ; 

Rhubarb,  or  jalap  ten  to  twelve  grains. 


If  there  is  no  gastric  irritability,  add  two  grains  of 
ipecac.,  or  a teaspoonful  of  tincture  of  lobelia.  If  the 
stomach  is  very  irritable,  with  much  nausea,  and  if  there 
should  be  great  febrile  excitement,  hot,  dry  skin,  &c., 
venesection  wfill  go  far  towards  allaying  it ; and,  soon 
after  the  blood-letting,  or,  if  it  is  not  thought  necessary  to 
resort  to  it,  give  from  a third  to  half  a grain  of  morphine, 
some  half  an  hour  or  an  hour  before  the  above  dose  of 
medicine  is  given ; and,  in  the  mean  time,  the  patient 
should  frequently  eat  small  quantities  of  ice,  which 
is  one  of  the  best  means  for  allaying  the  irritability 
and  nausea  of  the  stomach,  and  of  controlling  vomiting. 
Pouring  cold  water  over  the  head  and  neck,  and  over  the 
wffiole  body,  if  it  is  hot  and  dry,  has  also  a good  influ- 
ence ; not  only  in  controlling  the  irritability  of  the  sto- 
mach, but  in  controlling  the  fever,  oppression,  and  distress 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


265 


of  the  patient.  A piece  of  flannel,  folded  and  dipped 
in  a warm  mixture  of  laudanum,  brandy,  and  water,  is 
also  an  excellent  remedy  for  controlling  irritability  of  the 
stomach.  A cataplasm  of  peppermint  and  warm  brandy, 
or  mustard,  applied  in  the  same  way  over  the  region  of 
the  stomach,  may  be  used  for  the  same  purpose.  If 
the  first  dose  of  medicine  should  be  thrown  up,  endea- 
vor to  control  the  irritability  by  the  above  means,  and 
when  this  is  effected  repeat  the  dose,  leaving  out  the  mor- 
phine, if  it  has  been  given  before;  or  a sixty-grain  dose 
of  calomel,  either  alone  or  combined  with  the  morphine, 
may  suffice  to  control  this  irritability,  and  also  supersede 
the  exhibition,  for  a time,  of  the  first  dose  recommended 
above.  If  this  be  the  case,  the  patient  should  continue 
to  use  the  ice,  or  very  cold  water,  which  may  also  be 
poured  over  the  head  and  neck,  or,  if  necessary,  over 
the  whole  person.  In  two  or  three  hours,  a ten-grain  dose 
of  quinine  should  usually  be  given,  which  acts  as  a seda- 
tive, controlling  the  fever,  reducing  the  frequency  of  the 
pulse,  and  rendering  it  more  soft,  and  also  bringing  on 
warm  diaphoresis.  In  four  or  five  hours,  the  quinine,  with 
six  grains  of  jalap  or  a little  rhubarb,  and,  if  it  is  thought 
the  stomach  will  bear  it,  the  addition  of  two  grains  of 
ipecac,  or  a teaspoonful  of  the  tincture  of  lobelia  may 
be  given.  This  dose  may  be  taken  every  four  or  five 
hours  till  the  disease  begins  to  yield,  when  the  dose  of 
quinine  should  be  smaller,  say  from  four  to  six  grains, 
and  the  intervals  made  longer,  according  to  the  influ- 
ence  of  the  medicine,  and  the  readiness  with  which 
the  disease  yields.  About  twelve  or  twTenty-four  hours 
after  the  exhibition  of  the  first  dose  of  medicine  contain- 
ing calomel  it  should  be  repeated,  according  to  the  se- 
verity of  the  disease  and  the  influence  of  the  previous 
dose,  and  the  other  means  used  for  controlling  the  fever. 

18 


266 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


In  all  cases  that  are  disposed  to  be  obstinate,  it  may  be 
necessary  to  repeat  this  dose  the  third  time,  observing 
about  the  same  intervals  before  noticed — that  is,  twelve 
or  twenty-four  hours — and  it  will  generally  be  advisable 
to  make  the  second  and  third  doses  of  calomel  smaller 
than  the  first,  say  six  to  twelve  grains. 

For  the  irritability  of  the  stomach,  some  practitioners 
recommend  lime  water,  given  in  sweet  milk ; others 
sugar  of  lead,  in  from  three  to  five  grain  doses,  cam- 
phor dissolved  in  ether,  etc.  etc.  Dr.  Wood  speaks 
highly  of  a solution  of  the  citrate  of  potassa.  He  says: 
“No  preparation,  with  which  we  are  acquainted,  is 
equally  efficacious  in  allaying  irritability  of  stomach, 
and  producing  diaphoresis,  in  our  remittent  fevers.  If  is 
usually  also  grateful  to  the  stomach.”  I prefer  ice,  if  it 
can  be  obtained,  or  very  cold  water,  and  morphine,  with 
the  external  use  of  cold  water.  Iced  or  cold  water  is 
one  of  the  most  powerful  remedies  in  controlling  the  irri- 
tability of  the  stomach,  allaying  thirst,  producing  dia- 
phoresis, and  acting  in  concert  with  the  other  remedies 
to  control  the  fever.  This  article  is  generally  instinct- 
ively desired  by  the  patient,  and  it  is  usually  very  grate- 
ful to  him.  If,  however,  too  much  be  drank,  it  may 
subsequently  distend  the  stomach,  and  produce  nausea 
and  vomiting;  and,  therefore,  as  more  can  be  accom- 
plished by  a smaller  bulk,  ice  should  be  preferred.  The 
external  application  cf  cold  water  is  too  much  neglected 
by  practitioners.*  Indeed,  except  in  the  severest  forms  of 
the  causus,  the  use  of  the  lancet  may  be  entirely  super- 
seded by  the  former.  If  there  is  much  febrile  excitement, 
with  hot,  dry  skin,  the  patient  should  be  stripped  of  his 
clothing,  and  either  set  over  a tub,  or  laid  on  a blanket  on 
the  tloor,  and  have  cold  water  poured  freely  over  him  till 
the  heat  of  the  surface  becomes  cool,  and  the  fullness  and 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


267 


redness  of  the  skin  is  brought  to  a natural  appearance,  or 
even  paler  than  natural;  or  if  the  patient  should  begin  to 
complain  of  chilliness,  he  should  be  put  to  bed,  and  his 
feelings  consulted  with  regard  to  the  amount  of  covering. 
In  cases  of  less  violence,  or  in  the  causodes,  sponging  the 
whole  person  occasionally,  while  the  skin  is  hot  and  dry, 
may  suffice.  This  may  be  done  three  or  four  times  a 
day,  if  found  necessary  from  the  continuance  of  the 
fever.  To  more  particularly  enforce  the  importance  of 
the  external  application  of  cold  water,  I might  quote  a 
number  of  authors,  but  will  let  a few  extracts  from  Dr. 
Dickson’s  work  on  the  Practice  of  Medicine  suffice. 
He  says  it  is  one  of  our  most  efficient  febrifuges — 
“ far  above  the  lancet,  both  in  the  extent  of  its  adapta- 
tion and  in  its  degree  of  specific  utility.  All  that  we  can 
hope  or  anticipate  from  bloodletting,  may  be  obtained,  in 
a majority  of  cases,  by  the  use  of  the  [cold]  bath  ; while 
the  latter  possesses  this  striking  and  obvious  advantage, 
that  we  can  repeat  it  as  often  as  the  symptoms  are  re- 
newed that  require  it.”  And  further  : “ The  particular 
indications,  which  demand  the  resort  to  it  unhesitatingly, 
are  found  in  the  youth  and  general  vigor  of  the  patient, 
and  the  heat  and  dryness  of  the  surface.  The  local  deter- 
mination, which  it  controls  most  promptly,  is  that  to  the 
brain,  shown  by  headache,  flushed  face,  red  eyes,  deli- 
rium, etc.,  with  a full,  hard,  bounding  pulse.  Seat  your 
patient  in  a convenient  receptacle,  and  pour  over  his 
head  and  naked  body,  from  some  elevation,  a large 
stream  of  cold  wTater;  continue  this  until  he  is  pale,  or 
his  pulse  loses  its  fullness,  or  his  skin  becomes  corrugated 
and  he  shivers.  On  being  dried,  and  replaced  in  bed,  a 
general  sense  of  comfort  and  refreshment  will  attest 
the  benefits  derived  from  the  process,  which,  as  I have 
said  above,  may  be  repeated  whenever  the  symptoms 
are  renewed,  which  it  is  so  -well  adapted  to  remove. 


268 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


“If  the  shock  of  this  shower  bath  or  cataract  be 
too  great,  immersion,  which  many  prefer,  may  be  sub- 
stituted. Few  shrink  from  this,  and  almost  every  one 
will  evince  the  high  gratification  and  enjoyment  derived 
from  it.  One  of  the  pleasantest  effects  following  the 
bath,  is  the  complete  relaxation  of  the  surface,  which 
it  so  often  brings  on,  attended  with  a copious  and  salu- 
tary sweat.  I need  not  warn  you  against  the  nearly  ob- 
solete practice  of  endeavoring  to  accelerate  or  increase 
this  by  wrapping  in  blankets,  or  shutting  up  the  apart- 
ment, or  warming  it  artificially.  The  patient  is  to  be 
covered  agreeably  to  his  sense  of  comfort,  and,  though  I 
would  not  place  him  in  a current  or  draught  of  air,  I 
would  have  his  chamber  fully  and  freely  ventilated. 

“ Some  have,  strangely  enough,  imagined  it  to  be  neces- 
sary that  evacuations  of  some  kind  should  be  premised  to 
the  application  of  the  cold  bath,  but  this  is  a worse  than 
superfluous  caution.  It  does  positive  harm,  by  post- 
poning the  remedy  until  the  time  of  its  most  special 
adaptation  and  greatest  utility  is  past — the  earliest  and 
forming  stage  of  the  febrile  attack.  It  is  here,  I repeat, 
that  you  will  find  it  most  admirably  beneficial.  Yet  you 
will  meet  with  frequent  occasion  to  advise  its  repetition 
at  intervals  throughout  the  whole  progress  of  the  disease; 
and  even  when  the  patient  can  no  longer  bear  either  af- 
fusion or  immersion,  he  will  often  be  relieved  and  grati- 
fied by  washing  and  sponging  him,  especially  over  the 
hands,  arms,  breast,  feet,  and  legs.  In  the  very  latest 
stages  of  our  worst  fevers,  ablution  in  this  way  with  ar- 
dent spirits,  is  found  singularly  refreshing.” 

If  the  determination  to  the  head  is  considerable,  vio- 
lent, or  tenacious ; indicated  by  headache,  flushed  face, 
red  eyes,  beating  of  the  carotid  arteries,  in  some  cases 
delirium  ; the  patient’s  head  should  be  drawn  over  the 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


269 


edge  of  the  bed,  and  cold  water  from  a pitcher  or  bucket 
freely  and  frequently  poured  over  it,  and  over  the  back  of 
his  neck.  This  not  only  controls  the  cerebral  determi- 
nation, but  is  of  great  comfort,  and  soothing  to  the  feel- 
ings of  the  patient.  I would  urge  the  importance  of 
especial  attention  to  these  directions. 

In  the  language  of  Dr.  Dickson,  the  repetition  of  the 
external  application  of  cold  water  “is  forbidden,  when  it 
has  occasioned  a protracted  chill  or  rigor,  or  the  patient 
has  continued  to  feel  cold  or  uncomfortable  from  it.” 

When  the  skin  is  hot  and  dry,  and  the  patient  rest- 
less, the  cold  bath,  as  above  recommended,  is  eminent- 
ly grateful,  soon  producing  composure  ; and  perhaps  he 
will  fail  into  a pleasant  and  refreshing  slumber,  attended 
with  general  warm  diaphoresis.  But  notwithstanding 
the  great  febrifuge  virtues  of  this  remedy,  I believe  a 
large  majority  of  practitioners  seldom  resort  to  it ; and 
there  appears  to  be  fear  entertained  against  its  internal 
or  external  use  amongst  the  people  generally,  especially 
if  calomel  has  been  taken.  I have  often  been  under  the 
necessity  of  endeavoring  to  remove  this  groundless  fear. 
The  cold  bath  should  not  be  resorted  to  when  the  skin  is 
covered  with  sweat,  nor  should  it  be  used  so  freely  inter- 
nally when  this  is  the  case.  If  the  patient  is  feeble,  or 
much  debilitated,  and  the  skin  hot  and  dry,  pouring  the 
cold  water  over  the  head  and  neck,  and  merely  sponging 
the  body  as  occasion  requires,  should  be  resorted  to  in- 
stead of  immersion,  or  the  cold  dash  to  the  whole  person. 
In  the  causodes , the  sponging  wbli  generally  suffice.  If 
the  patient  should  be  very  much  debilitated,  very  old,  or 
when  the  skin  is  cool,  or  covered  with  sweat,  the  appli- 
cation of  cold  water  should  not  be  resorted  to. 

Cathartics. — At  the  commencement  of  the  treatment, 
if  the  bowels  are  not  already  relaxed,  it  is  advisable  to 


270 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


procure  a few  free  evacuations,  without  purging  vio- 
lently, after  which,  keeping  them  gently  relaxed  (one 
or  two  operations  a day)  is  sufficient.  For  this  pur- 
pose, the  extract  of  white  walnut,  the  extract  of  dande- 
lion and  rhubarb,  or  the  addition  of  a sufficient  amount 
of  rhubarb  or  jalap  to  the  quinine,  or  other  appropriate 
aperients,  will  suffice.  Cream  of  tartar  may  also  be  used, 
being,  too,  a cooling  and  grateful  drink  when  the  patient 
is  thirsty.  Lemon  juice,  diluted  with  water,  or  a solu- 
tion of  the  crystallized  citric  acid,  is  also  well  suited  for 
this  latter  purpose ; it  is  cooling,  and  produces  perspira- 
tion. Solution  or  infusion  of  slippery  elm,  or  gum  Ara- 
bic, may  also  be  used  as  a drink. 

In  the  early  stages  of  the  disease,  it  is  often  necessary 
to  use  some  tact  in  the  exhibition  of  medicines,  as  the 
stomach  sometimes  rejects  them.  When  this  is  the  case, 
a second  dose,  given  soon  after  the  vomiting  is  over,  will 
usually  be  retained.  If,  however,  the  irritability  of  the 
stomach  is  obstinate,  the  means  previously  recommended 
for  this  purpose  should  be  resorted  to,  or  a blister  maybe 
drawn  over  the  region  of  the  stomach,  and  dressed  with 
half  a grain  to  a grain  of  morphine. 

Calomel. — I most  decidedly  protest  against  the  exhi- 
bition of  calomel  every  two,  three,  or  four  hours,  as 
is  recommended  by  authors,  and  usually  put  in  prac- 
tice by  many,  perhaps  the  large  majority  of  physi- 
cians. Such  a course  as  this  usually  prostrates  the 
patient,  and  makes  the  disease  more  tenacious;  and  pro- 
duces irritation  and  inflammation  of  the  stomach  and 
bow!els.  It  should  not  be  given  oftener  than  has  already 
been  recommended,  and  its  exhibition  should  usually  be 
confined  to  the  first  few  days  of  the  disease.  If,  how- 
ever, inflammation  has  attacked  some  important  part, 
and  is  somewhat  tenacious,  a small  dose  of  calomel 
(four  or  five  grains)  or  blue  mass  may  be  given  once  in 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


271 


twenty-four  hours,  till  the  local  inflammation  yields.  If 
the  patient  is  observed  to  get  worse  every  day,  or  every 
other  day,  at  a certain  time  of  the  day,  the  calomel  should 
be  given  with  a dose  of  quinine  and  morphine,  or  opium, 
about  four  hours  before  the  commencement  of  the  par- 
oxysm, so  that  it  will  not  cause  the  bowels  to  operate 
during  the  paroxysm. 

Salivation  should  always  be  avoided.  It  may  be  ne- 
cessary, in  some  cases,  to  give  calomel  or  blue  mass,  so 
as  to  increase  the  saliva  to  the  extent  of  keeping  the 
mouth  and  tongue  moist,  and  making  the  patient  spit  a 
little  more  than  usual,  especially  in  those  cases  in  which 
local  disease  has  been  produced  and  is  tenacious;  but 
the  mercurial  influence  should  never  be  carried  to  the 
extent  of  making  the  mouth  and  tongue  sore.  Among 
the  many  useful  instructions  of  Dr.  Dickson,  I am  sorry 
to  see  that  he  and  others  are  still  under  the  misguided 
influence  of  preconceived  opinions  in  relation  to  the  libe- 
ral use  of  calomel.  We  might  expect,  however,  that  the 
older  practitioners,  who  were  taught  many  years  ago, 
when  calomel  was  the  great  remedy  in  all  cases  of  fever, 
would  still  hold  on  to  these  old  impressions  with  some 
tenacity ; notwithstanding  it  is  becoming  almost  obsolete, 
among  the  better  informed  and  most  successful  practi- 
tioners in  the  South. 

Emetics  are  usually  unnecessary  except,  in  some  cases 
at  the  commencement  of  the  disease,  there  should  be  un- 
digested food  in  the  stomach,  bile,  or  other  irritating 
matters ; when  this  is  the  case,  there  are  apt  to  be  nausea, 
retching,  or  incomplete  vomiting;  to  assist  which,  a tea- 
spoonful of  powdered  ipecacuanha  may  be  put  into  a 
teacupful  of  warm  water,  and  one-third  of  it  taken  every 
ten  or  fifteen  minutes  till  free  vomiting  is  induced  ; warm 
water  may  be  freely  drunk  to  assist  its  operation.  In  a 
severe  attack  of  the  causus,  tartar  emetic  may  be  given 


272 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


with  advantage,  instead  of  the  ipecacuanha;  and  during 
the  stage  of  excitement,  if  the  stomach  will  bear  it,  it 
may  be  of  much  service  in  controlling  this,  given  in  one- 
eighth  grain  doses  every  hour;  or  ipecacuanha  may  be 
given  for  the  same  purpose  in  two-grain  doses  every 
hour,  or  a grain  or  two  of  ipecacuanha,  with  a teaspoon- 
ful of  tincture  of  lobelia,  is  well  suited  for  the  same 
purpose;  so  also  is  a combination  of  a solution  of  mor- 
phine with  ipecacuanha  or  lobelia.  During  this  stage, 
lemonade,  a solution  of  cream  of  tartar,  soda,  or  Seidlitz 
powders,  are  also  grateful  to  the  patient,  and  cool  the 
fever  and  produce  sweating.  Usually,  emetics  should 
not  be  given  when  there  is  much  tenderness  or  pain  on 
pressure  in  the  region  of  the  stomach,  as  in  such  cases 
there  is  some  danger  of  their  setting  up  inflammation  of 
the  stomach  and  bowels,  which  will  render  the  case  more 
difficult  to  cure,  and  also  make  it  more  protracted.  When 
those  who  are  not  physicians  venture  to  give  emetics, 
ipecacuanha  should  generally  be  the  article  selected  for 
this  purpose,  as  it  may  be  given  with  greater  impunity 
than  tartar  emetic  or  lobelia;  and,  even  if  it  should  not 
be  thrown  up,  it  will  work  off  by  the  bowels  without  pro- 
ducing any  deleterious  effects.  In  mild  attacks,  a solu- 
tion of  common  salt  ( chloride  of  sodium),  or  mustard,  may 
be  given,  when  necessary,  as  an  emetic. 

Local  Blood-letting , I have  very  little  confidence  in,  in 
this  form  of  disease.  Dr.  Boling  seems  to  adhere  to  it 
on  account  of  preconceived  opinions,  but  remarks:  “ For 
the  relief  of  coma,  delirium,  and  epigastric  tenderness 
and  oppression,  I have  used  it  much,  but  seldom  with 
the  effect  of  producing  any  marked  and  immediate 
relief.” 

As  it  may  be  thought  strange  by  many,  especially  by 
those  of  the  North,  that  quinine  is  given  during  the  feb- 
rile excitement,  and  as  there  is  a prejudice  against  its  use 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


273 


during  this  time  by  some,  it  may  be  well  to  remark,  that 
when  given,  as  heretofore  recommended,  in  large  doses, 
it  has  a sedative  and  soothing  effect , reducing  the  fre- 
quency and  hardness  of  the  pulse,  and  producing  a gene- 
ral warm  diaphoresis.  If  it  is  given  in  doses  of  two  or 
three  grains,  and  not  properly  combined  with  other 
medicines  to  control  its  influence,  it  may  add  to  the  in- 
tensity of  the  disease — acting  as  an  excitant  or  stimulant, 
when  given  in  this  way.  Quinine  more  prominently 
manifests  its  favorable  influence  during  the  stage  of  re- 
mission, than  during  the  stage  of  excitement;  and  some 
are  in  the  habit  of  giving  it  in  large  and  frequently  re- 
peated doses  during  this  time,  so  as  to  avert  the  ensuing 
anticipated  stage  of  excitement.  In  many  cases  this  may 
suffice,  but  in  cases  attended  with  much  danger,  or  de- 
termination to  important  organs,  valuable  time  may  be 
lost  in  waiting  for  a remission;  therefore,  usually,  the 
better  plan  is  to  give  it  as  heretofore  advised.  When  it 
causes  roaring  in  the  head,  or  buzzing  in  the  ears,  the 
intervals  between  the  times  of  its  exhibition  should  be 
made  longer  (waiting  for  these  effects  in  a great  measure 
or  entirely  to  subside),  and  the  dose  diminished,  if  large 
ones  have  been  given.  Dr.  Boling,  of  Montgomery,  Ala- 
bama, to  whose  interesting  paper  on  the  subject  of  remit- 
tent fever,  in  the  American  Journal  of  the  Medical  Sci- 
ences, 1S46,  I would  refer  the  reader,  says,  that  “ Quin- 
ine is  decidedly  the  most  important  and  generally  useful 
therapeutic  agent  in  the  treatment  of  the  various  forms 
of  remittent  fever.”  In  corroboration  of  the  above  direc- 
tions, and  for  further  suggestions  or  instructions,  I will 
take  the  liberty  to  extract  a few  more  remarks  from  Dr. 
Boling’s  communication. 

“ The  impression  still  exists,  even  with  many  of  those 
who  venture  on  the  use  of  quinine  in  remittent  fever, 
that  it  is  only  during  the  remissions  that  it  should  be 


274 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


given,  and  that  mischief  must  certainly  be  the  result  of 
its  administration  during  the  exacerbation.  So  far  is 
this  from  being  true,  that  there  is  nothing  with  which 
we  can  more  effectually  aid  in  cutting  short  an  exacerba- 
tion than  the  quinine  itself,  commenced  and  administered 
freely  during  that  time.  In  most  of  the  cases  to  which 
I have  alluded,  in  which  I had  a suspicion  of  certain 
unpleasant  symptoms  being  produced  by  the  quinine, 
either  the  remedy  had  been  administered  at  so  late  a 
period  of  the  remission,  or  the  exacerbation  had  antici- 
pated so  much,  that  its  first  effect  upon  the  system  gene- 
rally was  felt  just  at  the  height  of  the  exacerbation.  But 
in  those  cases,  and  they  were  few,  in  which  unpleasant 
effects  even  seemed  to  be  produced  by  it,  it  rarely  failed 
to  diminish  the  length  of  the  exacerbation.  Undoubtedly 
the  action  of  the  quinine  is,  in  most  cases,  more  favorable 
during  the  remissions  than  during  the  exacerbations. 
Less  of  the  remedy  will  be  required  to  produce  its  pecu- 
liar effect,  and  this  may  more  promptly  be  brought 
about.  But  is  it  alone  in  this  respect?  Is  it  not  the 
same  with  almost  every  article  of  the  materia  medica? 
Who  ever  saw  a cathartic  act  as  mildly  and  as  efficiently, 
during  an  exacerbation  of  fever,  as  during  the  state  of 
of  remission.”  And  again  : — 

“ Great  mischief  has  been,  and  is  still  the  consequence 
of  this  impression,  that  a preparatory  treatment,  a reduc- 
tion of  the  force  and  violence  of  the  disease,  is  necessary 
for  the  administration  of  quinine.  Many  cases,  origin- 
ally mild,  under  this  course  of  preparation,  go  on  getting 
worse  and  worse,  and  further  and  further  from  the  sup- 
posed fitting  standard,  with  each  succeeding  exacerba- 
tion— while  other  cases  become  totally  irremediable  by 
any  course  of  treatment  after  a few  exacerbations — and 
cases,  too,  that  might  have  been  promptly  arrested  by 
quinine  at  the  termination  of  the  first  or  second  exacer- 


REMITTENT  FEVER— CAUSUS,  TREATMENT.  275 

bation.  It  is  only  the  originally  less  severe  cases  that 
will  bear  a long  continuance  of  any  system  of  treatment 
in  which  quinine  is  not  a principal  remedy.  Whenever 
a protracted  case,  presenting  violent  symptoms,  is  met 
with,  the  probability  is  ten  to  one  that  it  was  originally 
a mild  case,  treated  with  drastic  purgatives,  perhaps 
blood-letting  and  diaphoretics — and  entirely  without  qui- 
nine. Cases  originally  violent,  almost  invariably  die 
while  preparing  for  the  quinine,  and  those  of  moderate 
severity  become  worse  under  this  preparation  ; perhaps 
so  reduced  in  flesh  and  strength,  that  all  depletive  treat- 
ment has  necessarily  to  be  suspended,  without  any  abate- 
ment whatever,  almost  invariably,  indeed,  with  an  aug- 
mentation of  the  febrile  symptoms.  These  may  be 
subsided  slowly  after  the  suspension  of  treatment,  or 
sometimes,  although  the  fever  may  not  be  subdued,  the 
quinine  is  ventured  upon  in  consequence  of  the  debility, 
and  seems  to  prove  powerfully  tonic,  by  immediately 
arresting  the  progress  of  the  febrile  paroxysms,  and 
thus  permitting  the  healthy  exercise  of  the  organs  of 
digestion. 

“ Whatever  the  type  or  character  of  the  fever,  wher- 
ever there  is  reason  to  apprehend  danger,  no  time  should 
be  lost  in  bringing  the  system  decidedly  under  its  influ- 
ence. Where  the  remission  is  w7ell  marked,  and  of  some 
continuance,  I generally  prefer  this  period  for  its  com- 
mencement, probably  now  from  habit,  more  than  any- 
thing else.  Where  the  remissions  are  short,  or  when  the 
case  is  urgent,  and  there  is  reason  to  apprehend  a.  fatal 
termination  in  the  next  exacerbation,  or  where  the  dis- 
ease is  of  so  violent  a character  as  to  justify  fears  of  the 
occurrence  of  any  serious  organic  lesion,  or  a considerable 
aggravation  of  any  that  may  already  exist,  it  seems  to 
me  preferable  to  commence  with  it  immediately,  and  this 
I generally  do,  without  regard  to  the  stage  of  the  pa- 


276  REMITTENT  FEVER— CAUSUS,  TREATMENT. 

roxysrn.  The  fact,  that  the  exacerbations  frequently 
anticipate,  or  come  on  at  irregular  and  unexpected 
periods,  and  that,  too,  most  frequently  in  cases  of  such 
violence  as  to  require  decided  and  prompt  measures  for 
their  successful  management,  is  another  reason  for  the 
immediate  administration  of  the  quinine.  Two  portions, 
of  from  eight  to  sixteen  grains  each,  according  to  the 
urgency  of  the  symptoms,  given  within  a couple  of  hours 
of  each  other,  will  most  generally  bring  the  patient  under 
its  influence  two  or  three  hours  after  the  administration 
of  the  second  portion.  Where  the  case  is  of  a very  vio- 
lent character,  and  but  a short  period  is  allowed  the  phy- 
sician to  act,  before  the  time  of  the  expected  exacerbation, 
the  whole  of  the  above  amount  may  be  given  at  one 
time.  Wherever  the  physician  arrives  during  the  height 
of  the  exacerbation,  when  the  case  is  one  of  great  seve- 
rity, the  remedy  should  be  immediately  administered  in 
full  and  decided  doses,  for  the  purpose  of  preventing 
mischief  during  the  existing  exacerbation,  by  at  once 
bringing  the  arterial  system  under  its  sedative  action. 

“ The  system  once  fully  under  the  influence  of  the 
medicine,  about  eight  grains  every  third  or  fourth  hour 
will  generally  be  sufficient  to  effect  all  the  good  it  is  ca- 
pable of.  Larger  doses,  indeed,  may  be  given  with 
safety,  but  they  are  rarely  necessary,  and  frequently  add 
much  to  the  present  discomfort  of  the  patient.  Where 
any  decided  inflammatory  complication  exists,  the  re- 
medy should  be  continued  until  this  is  completely  sub- 
dued* as  its  too  early  withdrawal,  under  such  circum- 
stances, rarely  fails  to  be  followed  by  renewed  excitement 
of  the  arterial  system,  and  an  increase  in  the  local  in- 
flammation. Where,  however,  the  case  is  one  of  simple 
remittent,  of  quotidian  or  tertian  type,  the  remedy  need 
be  continued  but  a short  time  after  it  has  controlled  one 
exacerbation.  Where  the  type  is  that  of  a double  tertian, 


REMITTENT  FEVER— C AUSUS,  TREATMENT. 


277 


it  is  absolutely  necessary,  before  its  withdrawal,  that  two 
successive  exacerbations  should  be  controlled,  for  the  mere 
suspension  of  one  set  of  exacerbations  does  not  secure  the 
patient  against  a continuance  of  the  other.  Under  any 
circumstances,  however,  when  the  patient  is  once  strong- 
ly under  its  influence,  it  should  be  gradually  withdrawn,  as 
its  sudden  suspension  is  apt  to  be  followed  by  that  state 
of  reaction  wTich  so  frequently  follows  temporary  de- 
pressions of  the  circulation  from  other  causes. 

“The  best  evidence  of  the  favorable  action  of  the  re- 
medy, is  a diminution  in  the  frequency  of  the  pulse. 
This  is  generally  also  accompanied  by  an  increase  in  its 
volume,  where  it  has  been  small  and  corded,  and  where 
it  has  been  hard  or  firm,  it  becomes  soft.  An  abatement 
in  the  severity  of  the  other  symptoms,  soon  follows  this 
improvement  in  the  pulse.  The  skin  becomes  moist  and 
cool,  sometimes  even  so  much  so,  as  to  excite  considera- 
ble alarm  in  the  patient  or  his  friends.  This  coolness  of 
the  surface,  attending  the  perspiration  produced  by  qui- 
nine, may  be  readily  recognized  by  the  state  of  the  pulse 
and  other  marks  of  the  action  of  the  remedy,  and  of  an 
improving  condition  generally;  and  whatever  the  alarm 
of  the  patient  and  others,  the  initiated  can  smile  in  satis- 
factory security.  The  tongue  also  becomes  gradually 
moist,  the  thirst  diminishes,  and  an  improvement  in  the 
appearance  of  the  exacerbations  soon  succeeds. 

“ The  influence  of  the  remedy  once  fairly  induced  in 
the  system,  it  is  rare  for  another  exacerbation  to  follow, 
and  a gradual  and  continuous  amendment  generally 
goes  on  from  this  period.  Occasionally,  however,  an- 
other exacerbation  does  take  place,  and  during  its  con- 
tinuance, the  patient’s  situation,  in  some  cases,  is  more 
uncomfortable  than  during  any  previous  exacerbation. 
Not  that,  in  regard  to  the  symptoms  generally,  any  in- 
crease has  taken  place  upon  the  previous  exacerbation, 


278  REMITTENT  FEVER— CAUSUS,  TREATMENT. 

these  may  be  even  slightly  improved,  but  an  indescri- 
bable feeling  of  anxiety  and  distress  is  complained  of.  * * 

“ Sometimes,  the  system  being  apparently  under  the 
influence  of  quinine,  the  first  exacerbations,  after  this 
state  is  induced,  will  be  but  imperfectly  controlled,  and. 
the  case  perhaps  go  on  in  this  way  for  some  time,  each 
succeeding  one,  however,  being  less  and  less  severe,  till 
they  finally  yield.  At  other  times,  the  first  exacerbation 
after  the  system  has  been  brought  under  the  influence  of 
the  remedy,  will  seem  to  be  controlled  only  so  far  as  the 
heart  and  arteries  are  concerned,  the  pulse  remaining  at 
the  same  standard  as  during  the  remission  ; sometimes, 
indeed,  where  very  full  doses  have  been  given,  even  less 
frequent,  while  all  the  other  symptoms  give  evidence  of 
a severe  exacerbation.  The  tongue,  for  instance,  has 
again  become  dry, — supposing  it  not  to  have  been  so 
during  the  previous  remission, — while  the  thirst,  nausea 
and  vomiting,  heat  of  skin  and  general  distress,  all  attest 
a high  state  of  fever.  This  state  subsides  at  the  usual 
hour  of  remission,  if  not  before,  and  nothing  but  a con- 
tinuance of  the  remedy,  in  moderate  doses,  through  the 
period  for  the  next  exacerbation,  is  necessary  to  prevent 
its  recurrence.  Frequently,  indeed,  especially  in  cases 
taken  under  treatment  at  a sufficiently  early  period  to 
prevent  the  occurrence  of  serious  organic  lesions,  even 
this  further  continuance  of  the  remedy  will  be  unneces- 
sary, and  convalescence  may  be  considered  as  commenced 
with  the  subsidence  of  this  modified  exacerbation. 

“Although  it  is  in  all  those  varieties  or  shades  of  the 
disease  termed  pernicious,  and  recognized  as  such  at  first, 
that  the  quinine  should  be  most  promptly  resorted  to,  yet 
we  should  not  forget  its  insidious  character,  and  that  at 
times,  cases,  apparently  of  the  mildest  form  at  first,  sud- 
denly and  unexpectedly  assume  a grave  character,  and 
perhaps  prove  fatal  in  the  first  severe  exacerbation.  It  is 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


279 


true,  that  a large  majority  of  the  cases  of  simple  remit- 
tent fever,  if  drastic  purgatives,  emetics,  and  ‘ diapho- 
retic mixtures’  are  not  ventured  upon  too  freely,  may  be 
dallied  with  some  time  before  they  are  beyond  the  con- 
trol of  quinine,  yet,  every  now  and  then,  the  neglect  of 
its  early  administration  will  have  to  be  regretted. 

“ In  many  cases,  such  is  the  irritability  of  the  sto- 
mach, even  during  the  remissions,  that  we  cannot  rely 
with  any  certainty  on  a sufficient  quantity  of  medicine 
being  retained  to  produce  the  desired  effect — indeed,  in 
some  cases,  everything  is  rejected  almost  as  soon  as 
swallowed.  Under  such  circumstances,  the  quinine  may 
be  administered  in  enema  of  starch.  From  twenty  to 
thirty  grains  may  be  given  in  a couple  of  ounces  of 
starch,  every  second  hour,  till  the  system  is  brought 
fully  under  its  influence,  after  which,  its  effects  may  be 
sustained  by  less  frequent  repetitions,  say  every  third  or 
fourth  hour.  As  a stimulant,  the  opium  may  be  admin- 
istered in  the  same  way,  and  as  much  as  the  patient 
can  bear  without  narcotism,  say  from  forty  drops  of  the 
tincture  (laudanum)  with  each  of  the  first  three  or  four 
enemata,  and  double  that  quantity  when  the  intervals 
between  them  are  extended.  Sometimes,  when  diarrhoea 
exists,  and  especially  where  the  rectum  has  been  ren- 
dered irritable  by  the  previous  administration  of  laxative 
enemata,  there  is  some  difficulty  in  retaining  the  quinine. 
When  this  is  the  case,  the  irritability  of  the  rectum 
should  be  allayed  before  the  quinine  is  commenced  with, 
by  an  enema  of  starch,  containing  from  80  to  100  drops 
of  the  tincture  of  opium  alone.” 

In  contrasting  the  eminent  success  of  the  means  above 
recommended,  with  the  calomel,  blue  mass,  and  saltpetre 
practice  cff  some  ten  or  fifteen  years  ago,  I with  heart- 
felt pride  and  satisfaction  congratulate  the  present  gene- 
ration; while  I sympathize,  retrospectively,  with  those 


280 


REMITTENT  FEVER— CAUSUS,  TREATMENT. 


who  had  to  suffer  a long-protracted,  prostrating,  hurtful, 
dangerous,  and,  not  unfrequently,  fatal  treatment ; I 
allude  to  the  salivating  influence  of  calomel  and  llue 
mass , &c.  The  author  has  witnessed,  in  his  own  per- 
son, all  the  evils  above  enumerated,  except  the  last,  at 
as  late  a date  as  1840,  and  to  a much  less  extent  in 
1842.  I well  remember  that,  in  1840,  I was  taken  with 
this  form  of  remittent  fever  (the  causus),  which  I can 
now  arrest  with  little  or  no  difficulty  in  a few  days,  or 
sooner,  and,  having  called  in  a physician,  who  was  de- 
luded with  the  theory  of  Professor  Cooke — who  could 
trace  the  febrile  disturbance  to  nothing  but  a morbid 
condition  of  the  circulation  of  the  liver — I objected 
to  the  incessant  use  of  calomel,  blue  mass,  and  saltpetre. 
I recollect  his  reply:  “0,  I'll  fatten  you  on  it!'’  I 
took  these  (I  had  like  to  have  said  remedies)  articles 
for  several  weeks  without  their  checking  the  disease 
in  the  least;  and  when  the  fever  eventually  subsided 
of  its  own  accord,  these  were  still  exhibited,  till  they 
produced  intense  salivation,  sore  mouth,  spitting  of  blood 
for  weeks,  and  extreme  prostration,  until  I was  reduced 
almost  to  a skeleton,  and  unable  to  turn  over  in  bed. 
In  about  eight  vveeks  from  the  period  of  attack  I was 
able  to  walk  out  of  doors,  from  which  time  a tardy  and 
tedious  convalescence  ensued.  When  on  a visit  to  the 
State  of  Tennessee,  some  years  ago,  I called  to  see  a 
friend  whom  I found  near  the  gate  of  death,  who  had 
been  under  the  mercurial  treatment  of  the  Cookite 
above  referred  to,  for  a long  time.  I put  a stop  to 
this  treatment,  which  was  helping  him  on  to  the  tomb, 
and  had  him  put  under  the  quinine  treatment.  He 
immediately  began  to  improve ; but  his  system  had 
already  been  so  much  prostrated,  and  otherwise  inju- 
riously affected,  that  I do  not  believe  he  has  even  yet 


REMITTENT  FEVER— COMATOSE  FORM,  TREATMENT.  281 


fully  recovered  from  these  deleterious  influences.  The 
Cookite  alluded  to  is  also  a friend  of  mine,  and  while  I 
commend  his  devoted  and  assiduous  attentions  to  his  pa- 
tients, I can  but  pity  his  delusion,  and  wofully  sympa- 
thize with  those  who  suffer  from  its  results,  hoping  that, 
ere  long,  he  will  be  convinced  of  his  error,  and  abandon 
it.  These  are  only  examples  of  this  injurious  and  dan- 
gerous practice.  How  many  thousands  have  suffered  in 
a like  manner,  or  even  worse?  No  doubt  numerous 
graveyards  could  bear  ample,  though  silent  testimony,  to 
the  truth  of  these  remarks ! Nor  are  we  to  look  alone  to 
the  immediate  effects  of  this  baneful  practice,  which 
lays  the  foundation  of  so  many  chronic  maladies;  for. 
after  more  or  less  protracted  suffering,  the  patient,  who 
has  thus  had  his  constitution  irreparably  injured,  after 
dragging  out  a more  or  less  miserable  existence,  ulti- 
mately succumbs. 

If  the  means  previously  recommended  be  properly  car- 
ried out,  the  patient  and  his  friends  will  almost  invari- 
ably have  the  pleasing  satisfaction  of  seeing  the  afflicted 
speedily  restored  to  health.  In  the  management  of  this 
affection,  as  well  as  of  all  others  of  severity  and  dan- 
ger, the  people  should  learn  the  importance  of  secur- 
ing medical  aid  at  the  commencement  of  the  attack. 
Soon  after  the  incendiary’s  torch  is  applied  to  a building 
the  fire  may  easily  be  subdued,  but  after  it  has  progressed 
for  some  time  it  may  require  all  our  efforts,  which,  in- 
deed, in  some  cases  may  prove  abortive.  But  let  us  pro- 
ceed to  the  treatment  of  the  next  form  of  remittent  fever. 

3.  Treatment  of  the  Comatose,  or  Nervous  Form. 
— First,  give  quinine,  rhubarb,  and  calomel ; of  each,  ten 
grains;  or  twenty  of  the  latter  may  be  advisable;  to  which 
it  may  sometimes,  or  in  some  cases,  be  well  to  add 
two  grains  of  ipecacuanha  and  twenty-five  drops  of  laud- 
19 


282  REMITTENT  FEVER — COMATOSE  FORM,  TREATMENT. 

anum,  or  a teaspoonful  of  the  tincture  of  lobelia.  It  will 
usually  be  advisable  to  repeat  this  dose  in  twenty-four  or 
forty-eight  hours,  being  careful  to  combine  opiates  with 
it,  or  to  give  them  at  intermediate  times,  should  there  be 
a disposition  to  watery  evacuations  from  the  bowels.  A 
dose  of  quinine,  from  eight  to  fifteen  grains,  should  be 
given  about  every  six  hours;  and  as  there  is  sometimes 
a disposition  to  throw  it  up,  morphine,  one-third  to  one- 
half  grain,  or  laudanum,  ought  to  be  given  previously,  or 
combined  with  it,  and  flannel  or  other  woollen  cloth  may 
be  dipped  in  a warm  mixture  of  laudanum,  brandy,  or 
other  spirits,  and  water,  and  applied  over  the  region  of 
the  stomach ; or  sinapisms  of  mustard,  or  cataplasms  of 
peppermint  stewed  in  water;  or  water  and  brandy,  or 
whisky,  may  be  applied  in  the  same  way.  Though,  in 
some  severe  cases  of  this  form  of  remittent  fever,  the 
quinine  does  not  seem  to  have  so  prompt  and  decided  an 
influence  as  in  others,  and  in  the  other  forms  of  mala- 
rial fevers,  yet  it  appears  considerably  to  ameliorate  it. 
support  the  system,  prevent  extreme  prostration,  and  lead 
the  patient,  with  the  other  means,  safely  through  this 
obstinate  and  dangerous  scene.  About  five  or  six  days 
from  the  commencement  of  the  attack,  the  addition  of  a 
teaspoonful  of  tincture  of  puccoon  root  to  each  dose  of 
quinine,  appears  to  be  a good  combination.  If  the  patient 
desires  it,  he  should  be  allowed  to  drink  cold  water  or 
iced  water,  or  eat  small  quantities  of  ice,  drink  lemonade, 
or  a solution  of  citric  acid.  Cold  water  should  be  poured 
over  the  head  and  neck  occasionally ; and,  as  the  body 
or  general  surface  is  hot  and  dry,  it  should  be  frequently 
sponged  with  it.  Notwithstanding  the  skin  is  very 
dry  and  hot,  this  means,  in  many  cases,  does  not  seem 
to  produce  so  prompt,  decided,  and  manifest  an  in- 
fluence, as  is  observed  in  other  cases,  and  in  the  simple 
form,  the  causus,  or  causodes.  I have  never  resorted  to 


REMITTENT  FEVER— COMATOSE  FORM,  TREATMENT.  283 


the  cold  bath  or  immersion  in  this  form,  being  fearful 
that  it  might  produce  dangerous  or  even  fatal  prostration: 
but,  as  I have  never  tried  it,  I cannot  say  that  my  fears 
are  well  founded. 

Venesection,  in  this  form  of  remittent  fever,  I believe 
is  generally  unnecessary  and  unsafe.  In  some  cases,  in 
the  first  two  or  three  days  from  the  commencement  of 
the  attack,  in  which  there  are  considerable  determination 
to  the  brain,  fullness  about  the  face,  forehead,  and  tem- 
ples, with  injected  eyes,  I am  inclined  to  believe  that  a 
moderate  venesection — the  patient  being  in  a recumbent 
posture — is  sometimes  of  much  service  in  cutting  short, 
or  rather  preventing  a very  protracted  case,  by  its  own 
good  effects,  and  also  in  giving  the  other  remedies  a 
better  chance  to  exert  their  favorable  influence.  When 
this  is  thought  advisable,  it  will  be  proper  to  exhibit  qui- 
nine and  laudanum  previously,  so  as  to  have  the  system 
under  their  influence,  to  guard  against  prostration.  It 
appears  that  in  those  protracted  cases,  in  which  the  pulse 
is  hard,  quick,  and  wiry,  the  lancet,  judiciously  used, 
may  be  of  much  service.  Dr.  Campbell,  of  Columbia, 
Tennessee,  more  than  twenty  years  ago,  found  it  of  great 
advantage  in  this  latter  modification.  Dr.  Bell,  many 
years,  ago,  in  Virginia,  found  it  of  signal  service  in  the 
case  of  a little  black  girl,  who  had  been  sick  three  weeks. 
Notwithstanding  these  favorable  results,  it  should  be  re- 
sorted to  with  much  caution  and  judgment,  as,  if  inju- 
diciously practiced,  dangerous,  and  even  fatal  prostration 
may  be  induced.  Active  purging  should  also  be  avoided, 
lest  it  produce  the  same  result.  A few  rather  free  eva- 
cuations should  be  procured  the  first  tw~o  or  three  days  ; 
after  which,  one  or  two  a day  are  amply  sufficient; 
indeed,  in  the  latter  period  of  the  disease,  a stool  once 
a.  day,  or  every  other  day,  may  suffice,  it  being  prefer- 
able that  the  patient’s  bowels  should  be  rather  costive 


284  REMITTENT  FEVER— COMATOSE  FORM,  TREATMENT. 

than  too  loose,  or  disposed  to  run  into  the  typhoid  or 
fourth  form  of  remittent  fever.  For  aperients  in  this 
stage  of  the  disease,  we  may  profitably  use  extract  of 
dandelion  and  rhubarb  pills,  to  which  may  be  added, 
every  second  or  third  night,  two  grains  of  calomel,  or  a 
blue  mass  pill;  pills  made  of  extract  of  white  walnut, 
either  alone  or  combined  with  rhubarb;  and  if  necessary, 
every  second  or  third  night,  a little  calomel  or  blue  mass. 
If  the  bowels  should  be  disposed  to  purge  too  freely,  they 
should  be  controlled  by  laudanum  or  paregoric,  and,  if 
necessary,  the  addition  of  some  astringent,  as  tincture 
of  cinnamon,  krameria,  catechu,  kino,  tannin,  sugar  of 
lead,  &c. 

The  application  of  ten  or  a dozen  ears  of  corn  just 
taken  out  of  hot  water,  or  of  steam,  by  placing  a hot  rock 
in  a vessel,  which  should  be  placed  under  the  cover,  and 
the  water  poured  upon  it,  may  be  of  considerable  service 
in  moistening  and  softening  the  hot,  dry  skin,  and  con- 
tribute to  produce  sweating.  Warmth  may  be  applied 
to  the  extremities  when  they  are  cool  or  cold. 

In  the  latter  period  of  the  disease,  stimulants  and  sti- 
mulating aliments  should  be  given  to  sustain  the  vital 
energies,  and  prevent  the  patient  from  sinking  into  fatal 
collapse.  Port  wine,  brandy,  Maderia  wine,  wine  whey, 
and  the  like,  may  be  used  for  this  purpose ; as  also  pul- 
verized cayenne  pepper,  carbonate  of  ammonia,  &c 
Quinine  should  now7,  if  the  disease  has  sufficiently 
yielded,  be  given  in  doses  of  from  four  to  six  grains, 
three  or  four  times  a day,  with  the  addition  of  the  tinc- 
ture of  puccoon  root,  in  teaspoonful  doses;  or  less,  if  it 
nauseates.  Nourishing  diet,  such  as  the  stomach  can 
digest,  in  small  quantities,  frequently  repeated,  should  be 
regularly  given,  as  wane  whey,  weak  rice,  and  chicken 
soup,  panada,  etc.  etc.  During  the  first  w7eek  or  two 
after  the  commencement  of  the  attack,  the  patient’s  ap- 


REMITTENT  FEVER— TYPHOID  FORM,  TREATMENT.  285 


petite  is  generally  so  completely  annihilated,  that  he  can 
scarcely  be  induced  to  take  any  nourishment;  except, 
perhaps,  a little  coffee,  or  something  of  this  sort,  in  which 
some  crackers,  light  bread,  or  biscuit,  may  be  mashed 
and  soaked,  so  as  to  impart  a little  nutriment  to  the  fluid. 
As  convalescence  advances,  the  diet  should  be  improved. 

If  left  to  itself,  or  improperly  treated,  this  form  of  re- 
mittent fever  is  justly  considered  a dangerous  one  ; but 
when  taken  in  time,  and  properly  treated,  I believe  it 
may  nearly  always  be  controlled.  Fortunately,  it  occurs 
less  frequently  than  any  of  the  other  forms  ; but,  in  the 
progress  of  medical  improvement,  it  appears  that  we 
may  hope  soon  to  see  the  typhoid  form  as  rare  as  this — 
when  cathartics,  calomel,  and  emetics  cease  to  be  so 
much  abused,  or  relied  upon,  in  the  treatment  of  the 
other  forms  of  malarious  fevers. 

4.  The  Treatment  of  the  Typhoid  Form  or  Stage 
of  Remittent  Fever  consists  principally  in  the  use  of 
opiates , quinine , astringents , and  moderately  nourishing 
and  easily  digested  aliments.  A dose  of  quinine — from 
five  to  ten  or  twelve  grains — with  a dose  of  laudanum — 
from  twenty-five  to  sixty  drops — should  be  given  imme- 
diately on  being  called  to  a case  of  this  kind  ; and  forty 
or  sixty  drops  of  laudanum,  with  a solution  of  four  or 
six  grains  of  sugar  of  lead,  may  also  be  necessary  (if 
the  watery  discharges  from  the  bowels  are  copious  and 
frequent),  given  by  injection,  in  an  ounce  of  starch  or 
flour  gruel,  or  even  tepid  water  will  answer.  The  qui- 
nine should  be  repeated  four  or  five  time's  in  the  twenty- 
four  hours,  and  the  laudanum  two  or  three  times  a day, 
or  as  often  as  occasion  requires,  to  control  the  purging. 
If  the  purging  is  obstinate,  krameria,  tannin,  catechu, 
kino,  tincture  of  cinnamon,  sulphate  of  zinc,  or  even 
lunar  caustic — in  doses  of  from  half  a grain  to  a grain — 

O o 


286  REMITTENT  FEVER— TYPHOID  FORM,  TREATMENT. 

given  in  pill  of  crumb  of  bread,  in  which  there  is  no 
salt,  or  in  solution,  may  be  taken  with  the  laudanum  ; or. 
if  the  patient  cannot  take  laudanum,  opium  or  morphine, 
in  the  form  of  pill,  may  be  used.  These  should  be  given 
two  or  three  times  a day,  or  as  often  as  the  purging  de- 
mands their  use.  The  injections  may  be  given  two  or 
three  times  a day, — and  when  much  opiates  have  been 
given  by  the  mouth,  a correspondingly  less  quantity 
should  be  given  in  this  way, — bearing  in  mind  that  a dose 
by  injection  is  double  the  amount  given  by  the  mouth. 

In  this  form  or  stage  great  injury  is  often  done  by  the 
use  of  mercurial  cathartics,  by  those  who  erroneously 
suppose  that  the  bowel  affection  depends  on  congestion 
or  obstruction  of  the  circulation  of  the  liver.  I am  sorry 
to  see  that  this  delusion  still  holds  its  sway  even  among 
some  of  the  professors  or  lecturers  in  medical  schools, 
though  abler  ones  deprecate  their  use ; and  we  may  hope 
ere  long  to  see  this  erroneous,  dangerous,  and  often  fatal 
practice,  banished  from  the  minds  of  all  enlightened 
medical  men,  and  even  from  among  the  people,  who  have 
been  erroneously  taught  to  refer  too  many  disturbances 
of  the  system  to  derangements  of  the  liver. 

If  the  bowels  should  become  too  much  confined  by  the 
use  of  opiates  and  astringents,  a blue  mass  pill,  pills 
made  of  rhubarb  and  extract  of  dandelion,  or  rhubarb 
and  extract  of  white  walnut,  or  rhubarb  alone,  may  be 
given,  to  procure  a gentle  operation  once  in  a day  or 
two. 

If  there  should  be  determination  to  the  head,  cold  or 
cool  water  should  be  poured  over  it  and  over  the  back  of 
the  neck;  or  cloths,  dipped  in  cold  water,  may  be  applied 
to  the  head  ; and,  if  the  skin  is  hot  and  dry,  the  general 
surface  should  be  sponged  with  cool  water.  The  ex- 
ternal application  of  cold  water,  for  the  above  purposes, 
should  be  repeated  as  often  as  occasion  requires.  Plac- 


REMITTENT  FEVER— TYPHOID  FORM,  TREATMENT.  287 

mg  ten  or  a dozen  ears  of  corn,  just  taken  out  of  hot 
water, _ around  the  body  and  limbs  of  the  patient,  may 
also  be  of  service.  If  the  bowels  should  be  griped,  a 
woollen  cloth,  dipped  in  a warm  mixture  of  brandy,  lau- 
danum, and  water,  or  bran  that  has  been  made  as  warm 
as  the  patient  can  comfortably  bear,  put  into  a small 
pillow  case  or  bag,  or  wrapped  up  in  a cloth,  and  applied 
over  the  larger  portion  of  the  abdomen,  will  afford  great 
relief. 

As  the  disease  yields,  the  medicines  should  be  given 
in  smaller  quantities,  which  will  have  to  be  judged  of 
by  the  practitioner.  In  the  latter  stages,  stimulants 
should  be  given  in  addition  to  the  above-mentioned  reme- 
dies, as  camphor,  wine,  carbonate  of  ammonia,  capsicum, 
&c.,  and  also  some  moderately  nourishing  diet  every 
few  hours,  in  small  quantities  at  a time,  as  wine  whey, 
rice  and  chicken  soup,  or  squirrel,  or  beef  soup,  and  the 
like ; coffee,  in  which  crackers  or  biscuit  have  been 
soaked ; gruel,  arrowroot,  sago,  tapioca,  panada,  etc. 
etc.  In  the  latter  period  of  this  malady,  when  the  in- 
flammation of  the  bowels  is  tenacious,  sulphuric  acid 
is  a most  excellent  remedy  for  this  diseased  condi- 
tion ; it  also  exerts  a favorable  tonic  influence.  As  the 
quinine,  at  this  stage  of  the  disease,  usually  requires  to 
be  reduced  to  about  four  grains,  a convenient  way  of 
giving  the  sulphuric  acid,  is  in  solution  with  the  qui- 
nine. In  protracted  and  obstinate  cases,  together  with 
the  use  of  opiates,  this  important  article  should  not  be 
neglected. 

If  the  above  means  be  promptly  attended  to,  this  dis- 
ease may  soon  be  arrested,  and  convalescence  esta- 
blished ; but  if  it  be  neglected  or  improperly  treated  in 
the  early  stages,  it  will  be  more  obstinate;  perhaps  a case 
now  and  then  will  terminate  fatally,  or  the  convalescence 
will  be  slow  and  tedious ; perhaps  dropsical  swellings  of 


288 


REMITTENT  FEVER— DIET— CONVALESCENCE. 


the  feet,  ankles,  and  legs  take  place,  and  the  patient  is 
some  time  in  being  restored  to  perfect  health.  For  this 
swelling  of  the  lower  extremities,  and  concomitant  de- 
bility, muriated  tincture  of  iron,  in  doses  of  from  ten  tc 
twenty  drops,  three  times  a day,  taken  in  half  a glass  of 
water ; or  a mixture  of  precipitated  subcarbonate  of 
iron  and  cream  of  tartar,  as  in  the  following  formula, 
may  answer  well  for  these  conditions. 

1£.  Precip.  sub.  carb.  iron  two  ounces  ; 

Cream  of  tartar  four  ounces. 

Mix,  and  rub  well  together  in  a mortar.  Dose,  forty  to 
fifty  grains,  two  or  three  times  a day.  If  the  swelling 
of  the  feet  and  legs  should  be  troublesome  or  persistent, 
they  may  occasionally  be  bathed  in  strong  oak  ooze  ; or 
what  is  better,  envelop  them  at  night  with  a mush  poul- 
tice, made  up  with  strong  oak  ooze ; and  if  necessary, 
from  the  obstinacy  of  the  swelling,  apply  a bandage  in 
the  day,  commencing  at  the  toes,  and  wrap  the  limbs 
firmly  as  high  as  the  swelling  extends. 

Diet  and  Convalescence  in  the  different  Forms 
of  Remittent  Fever. — During  the  continuance  of  the 
fever,  unless  it  is  protracted,  or  extend  beyond  a week, 
little  or  no  advice  is  necessary  with  regard  to  diet,  as  the 
patient  usually  has  little  or  no  desire  for  food.  If,  how- 
ever, the  fever  should  be  checked,  or  the  remissions  com- 
plete and  of  some  duration,  and  the  patient  should  have 
some  relish  or  desire  for  nutriment,  he  may  be  allowed 
some  coffee,  in  which  crackers  or  loaf  bread  have  been 
soaked;  or  a little  wrnak  rice  and  chicken  soup,  a little 
thin  panada,  or  the  like.  One  or  two  leaves  of  benne 
may  be  put  into  a half  pint  of  water,  and  used  as  a nu- 
trient and  demulcent  drink.  If  the  patient  desires  it, 
lemon  juice  may  be  added  to  this,  or  use  it  separately. 


TREATMENT  DURING  CONVALESCENCE. 


289 


The  lemon  juice  or  lemonade  is  usually  very  much  re- 
lished by  the  patient,  and  may  be  pretty  freely  allowed. 
Gum  Arabic  or  slippery  elm  may  be  used  for  the  same 
purposes  as  the  benne,  and  prepared  in  the  same  way. 

If  the  disease  extends  beyond  a week,  or  is  protracted, 
it  will  be  advisable  to  pay  particular  attention  to  giving 
the  patient  regularly  such  articles  of  nutriment  as  are 
agreeable  to  his  stomach,  are  easily  digested,  and  some- 
what nourishing,  in  order  to  sustain  the  system  and  pre- 
vent too  great  prostration.  For  this  purpose,  the  articles 
above  mentioned  may  be  used,  or  arrowToot,  farina,  tapi- 
oca, sago,  beef  broth,  wine  whey,  boiled  milk,  with  a 
little  flour  in  it,  etc.  etc.  It  will  often  be  necessary  to 
vary  the  diet,  as  one  article  used  too  long  not  unfrequent- 
ly  becomes  offensive  to  the  patient.  Whatever  kind  of 
food  is  selected,  its  exhibition  in  a semi-fluid  condition  is 
nearly  always  preferable.  In  some  cases,  where  there  is 
much  debility,  and  the  stomach  will  not  retain  food  or 
nourishment,  it  should  be  given  by  injection  ; and  as  a 
frequent  repetition  of  the  same  article,  even  in  this  way, 
sometimes  becomes  offensive  to  the  patient,  it  will  be  ad- 
visable to  vary  it. 

Convalescence. — According  to  the  severity  of  the  at- 
tack, the  greater  or  less  implication  of  important  organs, 
and  the  means  that  have  been  employed,  will  be  the 
promptness  or  tardiness  of  convalescence.  If  the  prepa- 
rations of  mercury  have  been  too  freely  given,  we  may 
expect  that  convalescence  will  be  correspondingly  tardy; 
and  in  those  cases  in  which  affections  of  the  spinal  mar- 
row occur,  with  debility  or  partial  loss  of  the  use  of  one 
or  both  of  the  lower  extremities,  I am  inclined  to  princi- 
pally refer  to  the  protracted  and  injudicious  use  of  mercu- 
rials, to  the  neglect  of  the  use  of  quinine,  etc.,  as  hereto- 
fore recommended.  During  convalescence,  tonics  should 


290 


REMITTENT  FEVER. 


be  used  about  three  times  a day;  three  or  four  grain  doses 
of  quinine,  “bitters”  made  of  dogwood  bark,  gentian, 
quassia,  poplar  and  cherry  tree  bark,  Peruvian  bark, 
the  bark  of  the  willow,  etc.  etc.,  either  alone  or  combined, 
will  answer  this  purpose,  especially  if  the  system  has  not 
been  too  long  prostrated,  in  which  case  it  will  be  well  to 
add  some  of  the  preparations  of  iron ; as  the  subcarbonate, 
citrate,  tartrate  of  iron  and  potassa,  etc.  etc.  If  the  at- 
tack lias  not  lasted  a great  while,  the  addition  of  three 
quarters  of  a grain,  or  a grain,  of  sulphate  of  zinc,  at  a 
dose,  to  any  of  the  above-mentioned  vegetable  bitter 
tonics,  is  perhaps  preferable,  being  less  heating  than  the 
preparations  of  iron.  In  conjunction  with  the  use  of 
any  of  these  tonics,  Port  or  Madeira  wine,  or  a little 
brandy,  may  be  used,  especially  if  the  stomach,  or  rather 
the  appetite,  is  impaired,  defective,  or  irregular.  At  this 
time,  usually,  the  appetite  is  so  voracious,  that  it  will  re- 
quire some  efforts  on  the  part  of  the  patient  to  regulate 
his  diet  within  proper  limits,  otherwise  he  may  endanger 
a relapse;  or  sometimes  eating  too  much  may  only  pro- 
duce slight  febrile  disturbance,  and  impair  the  appetite 
for  a time.  The  patient  should  regulate  his  diet  in  that 
manner  which  is  best  calculated  to  nourish  and  invigo- 
rate the  system.  This  object  is  not  gained  by  taking  too 
much  or  too  rich  diet,  which  the  stomach  cannot  profit- 
ably manage,  and  which  may  oppress  it,  and  produce  a 
different  effect  from  that  which  was  contemplated.  Nor. 
on  the  other  hand,  should  he  go  to  the  other  extreme  of 
starving  himself  too  much.  His  diet,  first  light,  should 
be  more  and  more  nutritious,  as  he  finds  it  agreeable  to 
him,  till  he  is  able  gradually  to  return  to  his  ordinary 
mode  of  living.  If  the  patient  should  become  costive, 
some  of  the  milder  aperients  should  be  given,  such  as 
extract  of  white  walnut,  rhubarb,  a little  black-root  tea. 
cream  of  tartar  and  flowers  of  sulphur,  etc.  If  the 


TREATMENT  DURING  CONVALESCENCE. 


291 


bowels  should  become  too  loose,  opiates  and  astringents 
ought  to  be  given  to  check  them.  For  this  purpose,  a 
mixture  of  equal  parts  of  paregoric  and  tincture  of  cinna- 
mon may  be  given,  in  doses  of  from  one  to  two  teaspoon- 
fuls, as  often  as  occasion  requires.  If  it  prove  obstinate, 
laudanum,  with  some  of  the  astringents  heretofore  men- 
tioned, may  be  necessary. 

If  the  patient  should  become  restless,  or  troubled  with 
a morbid  vigilance,  it  may  be  controlled  by  a small  dose 
of  morphine  (quarter  of  a grain),  laudanum,  or  paregoric ; 
or,  if  these  should  not  agree  with  him,  hyosciamus, 
cicuta,  lactucarium,  and  the  hop  pillow  or  tincture  of  hop, 
may  severally  be  given,  trying  first  one  and  then  the 
other.  The  room  should  also  be  well  ventilated,  and,  if 
the  patient  is  costive,  a cooling  aperient  should  be  given, 
as  cream  of  tartar  and  sulphur,  or  cream  of  tartar  with 
the  addition  of  lemon  juice,  &c. 

During  the  continuance  of  the  disease,  the  patient 
should  not  be  allowed  to  receive  much  company,  nor  enter 
into  interesting  or  exciting  conversation,  nor  talk  too 
intently  for  some  time  on  one  subject,  and  it  is  also  of 
importance  during  convalescence  to  avoid  these.  If  he 
is  low  spirited,  the  family  and  friends  who  go  to  see  him 
should  endeavor  to  cheer  his  drooping  spirits  by  enliven- 
ing and  pleasant  conversation,  and  other  means  calcu- 
lated to  amuse  him. 

Before  the  patient  is  able  to  leave  his  bed,  he  should, 
as  frequently  as  is  agreeable  to  his  feelings,  change  his 
position  in  bed,  which  will  afford  him  some  exercise; 
and  the  bed  should  be  turned  about  and  placed  in  differ- 
ent parts  of  the  room  from  day  to  day,  so  as  to  change 
the  scenery,  and  as  much  light  may  be  admitted*  as  is 
agreeable.  All  the  medicines,  cups,  vials,  &c.,  which 
have  been  brought  into  the  sick  room,  except  those  that 
are  absolutely  necessary,  should  be  removed  from  his 


292 


REMITTENT  FEVER. 


view,  as  they  have  perhaps  become  offensive  to  him,  in 
bringing  to  his  remembrance  unpleasant  or  painful  recol- 
lections. 

When  the  patient  is  able  to  leave  his  bed.  he  should 
first  take  such  exercise  within  the  house  as  is  agreeable 
to  him ; and,  as  his  strength  improves,  he  may  venture 
out  into  the  open  air,  and  take  exercise  short  of  fatigue, 
either  by  a moderate  walk,  riding  in  a carriage,  and, 
finally,  on  horseback,  till  his  health  and  strength  are 
sufficiently  recovered  to  enable  him  to  resume  his  ordi- 
nary occupation.  He  should,  however,  for  some  time, 
avoid  perplexing,  complicated,  harassing,  or  disagreeable 
business. 

It  is  well  known  that  after  an  attack  of  remittent  fever, 
while  the  system  is  still  debilitated,  there  is  great  liability 
to  attacks  of  ague  and  fever.  This  is  unquestionably 
much  more  common  in  those  who  have  been  greatly  re- 
duced by  the  too  liberal  use  of  calomel  and  blue  mass,  a 
practice  which  is  now  becoming  obsolete  with  the  most 
intelligent  and  successful  practitioners  in  the  South. 
There  are,  however,  not  a few  who  are  behind  the  times, 
who  have  not  kept  pace  with  the  improvements  in  medi- 
cine; who  are,  to  a greater  or  less  extent,  bound  by  the 
shackles  of  the  past,  or,  indeed,  I might  properly  say, 
by  errors  which  are  still  extant. 

If  the  means  above  recommended  be  properly  carried 
out,  I believe  chills  and  fever  will  rarely  ensue.  If,  how- 
ever, they  should,  quinine,  and  other  remedies  recom- 
mended for  chills  and  fever,  will  soon  arrest  them. 

If  the  attack  should  have  been  in  the  spring  or  sum- 
mer season,  during  convalescence,  and  till  the  commence- 
ment of  the  ensuing  winter,  the  patient  may  be  greatly 
benefited,  by  sponging  his  whole  person,  every  morning, 
with  cool  water,  and,  when  his  system  is  able  to  bear  it, 
by  the  use  of  the  shower  bath.  This  tends  to  invigorate 


TREATMENT  DURING  CONVALESCENCE— JAUNDICE.  293 


the  system  and  prevent  relapse,  or  the  occurrence  of  ague 
and  fever.  If  the  attack  has  been  in  the  fall,  and  the 
system  much  prostrated  for  some  time,  it  may  be  well  for 
the  patient  to  wear  flannel  next  the  skin  during  the  en- 
suing winter  and  the  first  two  spring  months. 

Jaundice. — I should  have  remarked  that  during  or  sub- 
sequent to  an  attack  of  remittent  or  intermittent  fever. 
jaundice , or  yellowness  of  the  skin  and  whites  of  the 
eyes,  sometimes  makes  its  appearance.  This  yields  to 
the  treatment  adapted  to  the  remittent  or  intermittent 
fever,  but  it  should  be  less  vigorous.  Quinine,  and  an 
occasional  aperient,  of  which  calomel  or  blue  mass  may 
compose  a part,  unless  the  system  has  already  been  in- 
fluenced to  some  extent  by  these,  usually  suffice  to  effect 
a cure.  The  quinine  may  be  taken  in  doses  of  from  four 
to  ten  grains,  three  times  a day.  At  the  commencement 
of  the  treatment,  the  bowels  may  be  purged  moderately, 
after  which  an  aperient,  every  other  night,  will  perhaps 
be  sufficiently  often.  If  the  jaundice  {yellow  janders) 
should  persist  longer  than  six  or  seven  days,  it  will  com- 
monly be  advisable,  after  this  period,  to  give  aperients 
which  do  not  contain  any  calomel  or  blue  mass,  such  as 
extract  of  white  walnut,  a little  rhubarb  and  jalap,  cream 
of  tartar  and  sulphur,  &c.  Blood  root  (puccoon  root) 
may  alone  suffice  for  the  cure  of  jaundice.  It  should  be 
taken  three  times  a day,  diluted  with  water,  in  doses  of 
from  forty  to  sixty  drops  of  the  tincture,  or  from  two  to 
four  grains  of  the  pulverized  root  made  into  pills. 


294 


YELLOW  FEVER— DEFINITION  OF. 


CHAPTER  XIX. 

YELLOW  FEVER,  SOMETIMES  CALLED  “YELLOW  JACK,” 
“VOMITO”  “BLACK  VOMIT,”  ETC. 

I had  not  contemplated  saying  anything  on  the 
subject  of  lyelloiv  fever ; but,  as  the  improvements  in 
medicine,  of  late  years,  appear  to  be  working  a reforma- 
tion in  the  treatment  of  this  disease,  which  is  so  emi- 
nently successful,  compared  to  the  empirical  and  various 
modes  heretofore  practiced,  a brief  notice  of  it  may  not 
be  without  interest  to  the  reader. 

Some  consider  yellow  fever  but  a severer  form  of  re- 
mittent fever,  while  others  regard  it  as  a specific  disease. 
Dr.  Bartlett’s  definition  of  it  is  as  follows  : — 

“ Yellow  fever  is  an  acute  affection,  occurring  at  all 
ages,  but  much  more  frequently  during  the  middle  and 
active  period  of  life,  than  either  earlier  or  later;  attack- 
ing, in  a large  majority  of  instances,  persons  w’ho  are  not 
permanent  residents  in  the  places  w7here  it  prevails — 
sometimes  extending,  however,  especially  in  localities 
where  it  is  of  rare  occurrence,  to  such  residents ; rarely 
occurring  twice  in  the  same  person ; much  more  com- 
mon in  the  wThite  than  the  negro  race ; generally  milder 
in  its  character  amongst  children  and  women  than 
amongst  men ; confined  to  certain  geographical  localities, 
and  especially  to  commercial  seaports  in  hot  climates : 
prevailing  most  extensively  during  the  latter  part  of  the 
hot  season ; often  epidemic,  but  sometimes  sporadic  in 
its  appearance;  not  capable  of  transmission  from  one 
person  to  another  in  a pure  atmosphere;  depending,  for 
its  essential  cause,  upon  a poison  of  terrestrial  origin, 


YELLOW  FEVER. 


295 


the  nature  and  composition  of  which  are  entirely  un- 
known ; which  poison  may  be  shut  up  in  small  and  close 
apartments,  in  clothes,  bedding,  and  so  on,  and  trans- 
ported from  one  place  to  another,  and  which  is  destroyed 
by  a freezing  temperature ; sudden  in  its  access,  com- 
mencing with  an  initiatory  chill,  ordinarily  of  moderate 
severity,  and  of  short  duration  ; the  latter,  accompanied 
with  acute  and  violent  pains  in  the  head,  back,  and 
limbs,  or  immediately  followed  by  them,  then  by  a red 
suffusion  of  the  eyes,  moderate  heat  of  the  skin,  and 
moderate  acceleration  of  the  pulse  ; loss  of  appetite  and 
thirst;  a moist,  white,  villous  tongue,  with  rosy  tip  and 
edges:  these  febrile  phenomena  diminishing  in  activity, 
and  mostly  disappearing,  in  from  twenty  to  thirty-six 
hours.  The  first  stage  of  the  disease,  thus  characterized, 
passing,  in  mild  cases,  into  convalescence;  but,  in  grave 
cases,  being  followed,  after  an  interval  of  apparent  but 
deceptive  amelioration,  by  nausea  and  vomiting ; the 
matter  ejected  from  the  stomach,  in  cases  that  are  to  ter- 
minate fatally,  resembling  coffee  grounds ; black  or  dark 
colored  stools ; epigastric  distress ; general  restlessness, 
and  jactitation  ; sighing  respiration  ; hiccough ; a yellow 
color  of  the  skin  ; coldness  of  the  extremities,  gradually 
extending  to  the  trunk,  and  finally  by  death  ; the  mind 
usually  remaining  free,  but  apathetic  and  indifferent  up 
to  the  close  of  life,— which  symptoms  differ  very  widely 
in  their  degree  of  severity,  and  especially  in  their  number 
and  combination  in  different  cases,  thus  giving  rise  to 
different  varieties  and  grades  of  the  disease;  which 
symptoms,  furthermore,  may  either  subside  and  dis- 
appear in  the  course  of  a few  days  from  the  time  of 
their  commencement,  or  may  terminate  with  death,  be- 
tween the  third  and  seventh  day  of  the  disease ; the 
bodies  of  patients  exhibiting,  on  examination  after  death, 
in  most  cases,  a yellow  or  buff  color  of  the  liver,  with 


296 


YELLOW  FEVER. 


dryness  of  its  tissue;  black  spots  or  masses,  more  or  less 
numerous  in  the  lungs;  softness  and  flabbiness  of  the 
substance  of  the  heart,  and  in  nearly  all  cases  unusual 
thinness  and  fluidity  of  the  blood,  and  redness,  matrime- 
lonation  ; changes  in  the  thickness,  and  softening-one 
or  more — of  the  mucous  membrane  of  the  stomach  : 
this  organ  and  the  intestines  usually  containing  a con- 
siderable quantity  of  a very  dark  or  black  fluid,  or  semi- 
fluid matter,  which  disease  differs  essentially  from  all 
others  in  its  causes,  its  symptoms,  and  its  lesions ; and 
is  only  to  a moderate  extent  at  least,  in  its  graver  forms, 
under  the  control  of  art.” 

Dr.  Fenner,  of  New  Orleans,  in  speaking  of  the  epi- 
demic yellow  fellow  of  that  city  in  1S47,  says  : “ As 
usual,  the  epidemic  fevers  gradually  assumed  a graver 
type,  as  the  season  advanced.  Remittent  bilious  fever 
increased  considerably  in  June,  and  soon  after  the  1st 
of  July  was  merged  into  yellow  fever.  Some  of  the 
severe  cases  of  remittent  fever  resembled  yellow  fever  so 
much,  that  they  would  have  unquestionably  been  pro- 
nounced such  if  they  had  occurred  a month  later.  In- 
deed, cases  much  less  strongly  marked  than  some  of  these, 
were  pronounced  yellow  fever  during  the  prevalence  of 
the  epidemic.  But  it  is  customary  here  not  to  call  any- 
thing originating  here  yellow  fever  early  in  the  season, 
unless  black  vomit  is  seen,  or  has  occurred.  If  the 
patient  should  have  recently  arrived  from  Yera  Cruz  or 
Havana,  he  will  be  pronounced  yellow  fever,  no  matter 
how  light  his  symptoms.” 

Dr.  Fenner  further  remarks  : “ Many  cases  cannot  be 
distinguished  from  ordinary  remittent  and  even  intermit- 
tent fever,  unless  they  approach  a fatal  termination. 
Some  cases  admit  of  doubt  in  the  earlier  stages — if 
promptly  relieved,  there  is  doubt  after  they  recover — but 


* YELLOW  FEVER. 


297 


if  these  same  doubtful  cases  be  neglected  or  maltreated, 
and  terminate  fatally,  they  then  generally  become  plain 
enough.  How  often  do  we  find  doctors  differing  about 
the  character  of  a case  of  fever,  and  at  last  see  their  de- 
cision directed  more  by  the  attendant  circumstances  than 
by  any  real  value  of  the  symptoms  per  se.  If  the  case 
occur  when  yellow  fever  is  common,  the  slightest  simi- 
litude may  influence  the  judgment ; but  if  it  should, 
happen  to  be  the  first  suspicious  case  of  the  season , or 
should  occur  unusually  late , or  out  of  season  entirely, 
then  the  strongest  evidence,  such  as  black  vomit , hemor- 
rhage, etc.,  will  be  required  to  settle  the  question.”  In 
view  of  these  and  other  facts,  Dr.  Fenner  comes  to  the 
conclusion,  that  “ the  term  yellow,  like  the  term  conges- 
tive, as  applied  to  fever,  serves  more  properly  to  designate 
a condition  of  the  system  or  stage  of  disease,  than  any 
separate,  distinct;  or  specific  form  or  kind  of  fever. 
Symptoms  which  do  not  uniformly  distinguish  a disease 
from  all  others,  before  it  has  run  its  course,  or  until 
death  is  about  to  close  the  scene,  are  unworthy  to  be 
called  diagnostic. 

i£  During  our  late  epidemic,  all  the  forms  of  our  ende- 
mic fevers  were  to  be  seen,  such  as  intermittent,  remit- 
tent, congestive,  typhoid,  etc.,”  as  may  be  seen  by 
reference  to  the  statistics  of  fever,  in  the  early  part  of 
this  work,  page  20. 

The  total  number  of  interments  in  the  city  of  New 
Orleans,  from  the  3d  of  July  to  the  18th  of  October, 
1847,  inclusive,  wras  3990;  of  this  number  there  died  of 
yellow  fever,  2241.  The  total  number  of  interments  in 
the  city  of  Lafayette  (which  adjoins  New  Orleans,  im- 
mediately above),  from  the  26th  of  July  to  the  21st  of 
September,  inclusive,  was  793  ; of  which,  498  were  from 
the  yellow  fever.  “ Thus  making  the  total  deaths  of  all 
20 


298 


YELLOW  FEVER. 


diseases,  in  both  cities,  4873  ; of  which  2739  were  from 
yellow  fever.”* 

The  yellow  fever  appeared  as  an  epidemic  in  New 
Orleans  in  1839, 1841,  and  1847.  It  is  thought  that  some 
twenty  or  twenty-five  thousand  cases  occurred  during 
its  prevalence  in  1847.  As  in  all  other  fevers,  the  poorer 
classes  suffered  most  severely.  “ The  localities  around 
the  two  markets,  St.  Mary’s  and  Poydras,  in  the  Se- 
cond Municipality,  being  densely  inhabited  by  the  lower 
order,  were  severely  scourged.  But  it  really  appeared 
that  the  amount  of  sickness  in  different  quarters  was  re- 
gulated more  by  the  character  of  the  population,  than  by 
anything  specially  'pertaining  to  the  locality.  The  popu- 
lation about  New  Orleans  is  proverbially  restless  and 
movable  ; hence  many  persons  were  taken  sick  on  their 
passage  from  the  city — some  on  board  of  steamboats  going 
up  the  river,  others  at  the  summer  retreats  across  the 
lake,  as  Covington  and  Mandeville,  Pass  Christian, 
Pascagoula,  Biloxi,  etc.”  And  further  : “ Those  quarters 
suffered  the  most  which  contained  the  largest  number  of 
recent  and  unacclimated  inhabitants.  Amongst  these, 
the  poorer  classes,  as  usual,  suffered  the  most,  on  ac- 
count of  their  manner  of  living,  exposure  to  the  exciting 
causes,  imprudence,  etc.”  But  I have  already  extended 
these  remarks  beyond  what  I anticipated,  and  must  recur 
to  the  treatment,  for  which  purpose  principally  I here 
introduce  this  chapter. 

As  in  other  fevers,  we  find  the  nervous  system  is 
greatly  affected,  and,  perhaps,  concomitantly,  the  blood  . 
the  muscular  power  is  almost  annihilated,  and  the  pa- 
tient prostrated.  As  in  remittent  fever,  if  the  patient 
dies,  post-mortem  examination  sometimes  reveals  patho- 
logical lesions  most  prominently  in  one  organ;  and,  in 


* See  New  Orleans  Med.  Journ.,  Sept.  1848. 


YELLOW  FEVER— TREATMENT. 


299 


other  cases,  another  part  may  suffer  most  severely ; there- 
fore, we  need  not  look  for  a local  lesion  as  the  cause  of, 
or  characteristic  of,  the  disease.  It  appears  that  the 
stomach  is  found  most  frequently  affected ; but,  in  this 
age  of  delusion,  with  regard  to  the  liver,  many  look  to  it, 
not  only  as  the  principal  organ  affected,  but  erroneously 
imagine  that  this  hypothetical  affection  of  the  liver  is  the 
cause  of  the  disease.  Dr.  John  Harrison  says:  “As  for 
the  liver,  the  symptoms  of  the  disease  throughout  its 
whole  course,  as  well  as  post-mortem  examinations,  show 
that  it  is  by  no  means  particularly  affected.  The  passage 
of  bilious  stools,  during  the  first  days  of  yellow  fever,  is 
as  common  an  occurrence  as  we  meet  with,  though  not  a 

7 O 

grain  of  any  mercurial  has  been  taken.  We  find,  also, 
bile  in  the  gall  bladder  after  death,  so  that  the  whole 
argument  about  the  liver  is  just  upset  by  these  facts.” 

Treatment. — This,  as  in  remittent  fever  and  other 
diseases,  should  be  conducted  upon  general  principles, 
according  to  the  nature  and  severity  of  the  attack,  the  at- 
tendant or  accompanying  symptoms  or  phenomena,  the 
implication  of  important  organs,  and  the  stage  of  the 
disease. 

From  the  nature  of  yellow  fever,  and  a review  of  the 
different  modes  of  treatment,  I feel  pretty  well  assured 
that  it  should  be  conducted  on  the  same  general  princi- 
ples laid  down  for  the  treatment  of  the  different  forms  of 
remittent  fever ; the  milder  cases  requiring  a correspond- 
ingly mild  treatment,  the  severer  ones  demanding  a more 
prompt  and  vigorous  one. 

At  the  commencement,  I should  think  it  advisable  to 
give  a dose  composed  of 

R . Quinine  from  ten  to  twenty  grains  ; 

Rhubarb  from  ten  to  twenty  grains  ; 

Calomel  from  eight  to  twenty  grains. 


300 


YELLOW  FEVER— TREATMENT. 


Mix,  and  give  at  once.  If  the  patient  should  be  in  any 
pain,  or  if  there  be  irritability  of  the  stomach,  morphine 
(one-third  to  a half  grain),  or  some  other  opiate  should 
be  given,  either  with  this  dose,  or  prior  to  it,  in  order 
to  allay  the  irritability,  and  to  relieve  any  pain  or 
distress.  If  the  stomach  should  be  very  irritable,  or 
the  fever  high,  with  hot,  dry  skin,  I would  insist  on 
the  pretty  free  use  of  ice.  Let  the  patient  chew  it 
up  and  swallow  it,  so  that  it  may  dissolve  in  the  sto- 
mach. I wish  that  the  profession,  and  the  people 
generally,  were  aware  of  the  great  importance  of  ice 
in  the  treatment  of  the  remittent  fevers  of  the  South, 
especially  in  the  severer  forms,  attended  with  hot,  dry 
skin,  and  irritability  of  the  stomach,  and  vomiting.  The 
patient  should  be  allowed  to  eat  ice  pretty  freely,  yet  so 
as  not  to  overload  and  oppress  the  stomach.  It  acts 
finely,  not  only  in  controlling  the  gastric  irritability, 
but  in  allaying  restlessness,  and  the  general  irritability 
of  the  system,  contributing  to  the  tranquillity  and  com- 
posure of  the  patient,  and  producing  moisture  of  the 
skin,  or  sweating.  In  the  course  of  five  or  six  hours,  the 
quinine  should  be  repeated,  in  a dose  of  from  ten  to 
twenty-five  or  more  grains ; and  afterwards  repeated 
three  or  four  times  a day  in  large  doses,  for  the  first 
two  or  three  days,  or  till  the  febrile  excitement  is  con- 
trolled, and  then  it  should  be  given  in  doses  of  from  four 
to  six  grains  three  times  a day,  combined  with  other 
medicines,  as  the  condition  of  the  patient  may  seem  to 
require.  If  he  desire  it,  he  may  be  allowed  lemonade,  as 
an  occasional  drink.  If  he  should  have  sour  stomach, 
dissolve  supercarbonate  of  soda  in  a little  water,  and  add 
a little  tincture  of  cinnamon,  compound  tincture  of  car- 
damom, or  the  like,  and  let  him  drink  it  as  occasion 
requires. 

If,  in  the  early  stage  of  the  disease,  the  febrile  excite- 


YELLOW  FEVER— TREATMENT. 


301 


raent  should  be  very  great,  and  any  important  organ — 
as  the  brain,  stomach,  etc. — is  likely  to  suffer  in  conse- 
quence, a venesection,  corresponding  in  amount  to  the 
constitution  and  vigor  of  the  patient,  and  the  extent  of 
the  excitement,  may  be  demanded.  Sponging  the  whole 
person  with  cold  or  cool  water  may  also  be  useful  in 
allaying  the  fever  and  relieving  the  head,  especially  by 
its  frequent  application  to  the  latter.  The  body  should 
not  be  sponged  with  the  water,  except  when  the  skin  is 
hot  and  dry;  it  should  also  be  discontinued,  if  it  produce 
chilliness.  After  the  third  day,  sponging  it  occasionally 
with  a mixture  of  water  and  brandy  may  be  of  some 
service. 

At  the  commencement  of  the  treatment,  a fewT  mode- 
rately free  evacuations  from  the  bowels  are  desirable ; 
after  which,  purging  ought  to  be  avoided ; one  or  two 
mild  operations  a day,  or  less  frequently,  being  amply 
sufficient.  If  any  medicine  should  be  necessary  for  this 
purpose,  the  mildest  aperients  ought  to  be  selected,  such 
as  rhubarb,  flowers  of  sulphur,  cream  of  tartar,  etc.  If 
the  bowels  should  be  too  loose,  a little  paregoric,  a com- 
bination of  paregoric  and  tincture  of  cinnamon,  laudanum, 
etc.,  ought  to  be  given  to  restrain  them  within  proper 
limits.  Opiates  should  be  given  at  any  stage  of  the  dis- 
ease, wdien  the  irritability  of  the  stomach,  vomiting,  or 
pain  and  distress  of  the  patient  demand  their  use.  If  the 
patient  is  not  seen  till  the  black  vomit  has  appeared,  I 
would  give  immediately  a free  dose  of  laudanum  and 
quinine ; and,  if  the  prostration  demanded  it,  the  concomi- 
tant administration  of  brandy,  wine,  or  other  spirits;  to- 
gether with  the  application  of  a mixture  of  hot  brandy, 
water,  and  laudanum  over  the  region  of  the  stomach,  as  is 
recommended  for  vomiting-  in  remittent  fever.  Indeed, 
this  should  be  applied  over  the  stomach,  to  allay  nausea 
and  vomiting,  in  any  stage  of  the  disease ; and  the  patient 


302 


YELLOW  FEVER— TREATMENT. 


should  also  eat  ice.  After  the  third  day,  the  system  is  usu- 
ally so  much  prostrated,  that  it  will  require  the  use  of  small 
doses  of  quinine  (four  to  six  grains,  three  times  a day), 
camphor,  brandy,  or  wine,  wine  whey,  and  other  nourish- 
ing articles  of  diet,  that  are  easy  of  digestion  and  agree 
well  with  the  stomach;  as,  panada,  with  a little  wdne ; 
coffee,  in  which  crackers  or  biscuit  have  been  soaked, 
rice  and  chicken  soup,  beef  soup,  etc.,  made  palatable 
with  salt  and  pepper,  or  other  condiments. 

The  apartment  of  the  patient  should  be  well  ventilated 
and  dry;  the  second  story  of  buildings  in  southern  damp 
regions  being,  therefore,  preferable  to  the  lower  ones. 
The  apartment  should  also  be  kept  rather  dark  and  quiet, 
no  more  company  being  admitted  than  is  sufficient  to 
attend  to  the  sick. 

If  the  irritability  of  the  stomach  will  not  permit  it  to 
retain  quinine  and  opiates,  they  should  be  given  by 
injection,  or  applied  to  a blistered  surface. 

Such  I believe  to  be  the  general  principles  which 
should  guide  us  in  the  treatment  of  yellow  fever ; but,  as 
the  exhibition  of  quinine  in  large  doses,  in  the  early 
period  of  the  disease,  is  different  from  the  modes  which 
have  heretofore  principally  been  in  vogue,  I will  make  a 
few  quotations  in  order  more  fully  to  impress  the  impor- 
tance, nay,  the  absolute  necessity  of  promptly  resorting 
to  this  potent  remedy.  Dr.  E.  D.  Fenner,  of  New  Or- 
leans, in  alluding  to  this  method,  says : “As  practiced  by 
Dr.  McCormick,  it  is  as  follows — when  the  fever  is  fully 
developed,  a purgative  enema  and  mustard  foot-bath  are 
first  used,  and  from  15  to  30  grains  of  quinine  then  given 
to  subdue  the  fever.  If  the  pain  in  the  head  is  very  violent , 
he  is  bled  from  the  arm,  or  cups  are  applied  to  the  mas- 
toids;  otherwise,  blood-letting  is  dispensed  with.  The  large 
dose  of  quinine  seldom  fails  to  reduce  the  excitement  in 
a few  hours,  and  then  he  gives  15  or  20  grains  of  calomel 


YELLOW  FEVER— TREATMENT. 


303 


with  or  without  as  much  of  the  quinine  combined.  The 
foot-baths  and  enemata  are  repeated  pro  re  ncita;  the 
bov/els  are  freely  purged;  the  fever  vanishes,  and  the 
patient  seldom  requires  more  than  the  third  dose  of 
quinine. 

“ Dr.  Wedderburn  first  orders  an  enema,  consisting  of 
a tablespoonful  of  mustard  in  a quart  of  warm  water, 
which  he  says  evacuates  the  lower  bowels  more  promptly 
and  efficiently  than  anything  else.  Then  comes  the  hot 
mustard  foot-bath,  and  afterwards  the  following  dose  : — 

BL  Pulv.  rhei.  ten  grains; 

PuIy.  ipecac.  two  grains  ; 

Calomel  five  grains ; 

Sulph.  quinine  one  scruple. 

Mix  in  syrup,  and  give  at  once.  Sometimes  he  first  gives 
15  or  20  grains  of  quinine  with  20  or  30  drops  of  lauda- 
num suspended  in  water,  and  the  above  powder  imme- 
diately afterwards.  This  purges  freely  in  six  or  eight 
hours,  and  the  quinine  and  laudanum  are  afterwards  re- 
peated according  to  the  pain  and  fever.  The  purgative 
mentioned  happened  to  be  the  one  he  mostly  used  last 
summer ; he  admits  that  some  other  might  have  done  as 
well.  This  is  his  most  general  course.  If  the  attack  be 
very  severe,  and  the  patient  suffers  violent  pain  in  any 
part,  he  at  once  gives  from  20  to  30  grains  of  quinine, 
combined  with  40  or  50  drops  of  laudanum,  or  2 or  3 
grains  of  opium.  According  to  Dr.  W.,  this  dose  rarely 
fails  to  extinguish  both  the  fever  and  pain  in  a few  hours. 
Drs.  McCormick  and  Wedderburn  both  speak  in  the 
most  exalted  terms  of  their*  methods  of  treating  yellow 
fever.  Dr.  W.  never  bleeds  from  the  arm , and  very  sel- 
dom orders  either  cups  or  leeches.  Other  physicians 


* New  Orleans  Med.  and  Surg.  Journ.,  Sept.  1848. 


304 


YELLOW  FEVER— TREATMENT. 


here  use  quinine  freely  in  yellow  fever,  but  not  like  the 
above-named  gentlemen,  to  cut  the  fever  short  at  once 
Professor  John  Harrison,  M.  D.,  of  New  Orleans,  says  : 
“ The  new  mode  of  administering  the  sulph.  quinine  con- 
sisted in  waiting  for  no  abatement  of  the  fever,  but  in 
promptly  giving  the  sulph.  quinine  as  soon  as  possible 
after  the  attack.  The  dose  varied  from  20  to  80  grains, 
given  in  a little  cold  water.  If  the  stomach  was  very 
irritable,  it  was  given  by  injection.  When  the  practice 
was  first  introduced,  a cathartic  was  generally  first  given, 
and  the  administration  of  the  quinine  deferred  until  the 
bowels  were  moved.  This  practice  was  afterwards  aban- 
doned, on  account  of  the  loss  of  valuable  time.  In  strong 
and  robust  constitutions,  the  lancet  was  employed  for  the 
purpose  of  producing  a temporary  remission,  during 
which  the  quinine  was  given.  This  practice  was  de- 
cidedly beneficial.  If  the  first  dose  failed  in  eight  or  ten 
hours  to  produce  an  apyrexia,  a second  was  given.  The 
earlier  it  was  given  the  better ;”  but,  according  to  Dr. 
Harrison,  “it  should  not  he  given  after  the  second  day.” 
Dr.  H.  says  he  has  given  it  on  the  third  and  fourth  days, 
but  always  wkh  injury  to  the  patient.  I suppose  the 
cause  of  this  was,  that  Dr.  H.  continued  to  give  the  quin- 
ine in  large  doses;  and  should  this  have  been  so,  we  have 
no  reason  to  expect  that  it  would  have  produced  other 
than  injurious  results;  which,  in  congestive,  remittent, 
or  intermittent  fevers,  is  always  the  case  when  thus 
administered  after  the  fever  has  been  controlled  by 
the  remedy.  After  the  second  or  third  day,  when  the 
febrile  excitement  has  been  controlled,  I would  suggest 
the  use  of  lemonade,  with  small  doses  of  quinine  and 
puccoon  root.  Dr.  Harrison  says  : “The  fever  subsides 
on  the  third  or  fourth  day  ; the  pulse  and  skin  are  good ; 
the  patient  complains  of  no  pain,  and  the  physician  sup- 


YELLOW  FEVER— TREATMENT. 


305 


poses  him  out  of  danger.  The  truth  is,  the  danger  is 
then  most  imminent,  the  most  critical  period  of  the  dis- 
ease has  arrived,  and  the  patient  is  required  to  be  watched 
more  assiduously  than  ever.  It  is  at  this  stage,  that  a 
purgative,  or  any  other  medicine  improperly  administered, 
may  decide  his  fate.” 

After  alluding  to  the  new  mode  of  administering  qui- 
nine, which  it  appears  was  first  adopted  in  New  Orleans 
by  Dr.  J.  M.  Mackie,  at  the  suggestion  of  Dr.  Thomas 
Hunt,  in  1839,  Dr.  Harrison  observes:  “So  much  for 
the  method  of  administering  the  sulphate  of  quinine;  it 
now  remains  to  speak  of  its  effects.  The  fever  in  most 
cases  was  cut  short,  as  if  by  enchantment.  I shall  never 
forget  the  surprise  I felt,  the  first  time  I witnessed  its 
effects.  Three  patients  in  the  wards  of  Dr.  Mackie  -were 
put  under  its  influence.  The  conditions  of  the  three 
were  pretty  much  the  same,  as  also  were  the  results  ; the 
description  of  one  case  will,  therefore,  suffice  for  the 
whole.  The  patient,  a robust  young  man,  about  twenty- 
eight  years,  had  been  taken  with  yellow  fever  at  1 P.  M. 
He  was  prescribed  for  the  same  day,  at  6 P.  M.  Ten 
cups  were  ordered  to  the  epigastrium,  30  grains  of  sulph. 
quinine  to  be  taken  by  the  mouth,  immediately  after  the 
cupping,  and  40  grains  by  injection.  He  had  been  cupped 
before  I saw  him,  but  had  not  yet  taken  the  quinine. 
His  condition  was  as  follows  : pulse  120,  full  and  strong ; 
great  heat  of  skin;  great  pains  in  the  head,  back,  and 
lower  extremities;  tongue  a little  furred;  eyes  heavy, 
and  a little  injected ; great  restlessness  on  account  of  the 
pains.  I saw  him  next  morning,  between  6 and  7 
o’clock.  He  was  perfectly  free  from  pain ; the  pulse 
was  at  84 ; skin  cool ; in  short,  every  vestige  of  disease 
had  disappeared.  From  prudential  motives,  he  was  kept 
in  the  hospital  four  or  five  days,  and  then  discharged. 
There  was  never  any  return  of  the  disease. 


306 


ACUTE  RHEUMATISM. 


“ The  other  cases  terminated  in  a similar  manner,  and 
the  practice  was  soon  adopted  by  a number  of  physicians, 
myself  among  the  number.  The  results  were,  in  gene- 
ral, highly  satisfactory.” 

In  concluding  his  remarks  on  this  subject,  Dr.  Harri- 
son says : “ In  cases  in  which  the  fever  is  well  and  fully 
developed,  it  will,  unquestionably,  cut  that  fever  short, 
and  thus  prevent  the  formation  of  those  local  congestions 
which  are  produced  by  the  febrile  action.  In  this  con- 
sists its  value,  and,  assuredly,  it  is  a great  one.”* 

In  those  persons  who  are  unpleasantly  affected  by  the 
quinine,  the  ferrocijanate  of  quinia , in  five-grain  doses, 
may  be  used  instead. 

At  the  commencement  of  convalescence,  great  care 
should  be  taken,  lest  a relapse  be  brought  about ; as,  by 
leaving  the  bed  too  soon,  exposure,  etc.  Subsequently, 
the  remarks  made  in  relation  to  convalescence  from  re- 
mittent fever  are  applicable  here. 


CHAPTER  XX. 

ACUTE  RHEUMATISM. 

I here  merely  call  the  attention  of  the  reader  to  the 
subject  of  acute  rheumatism,  to  inform  him  that  it 
promptly  yields  to  the  treatment  adapted  to  intermittent 
or  remittent  fever.  This  disease,  which  has  caused  so 
much  pain  and  distress,  in  all  past  ages,  to  those  who 
have  been  unfortunate  enough  to  be  attacked  by  it ; the 
perplexity  it  has  given  to  the  profession — or,  indeed,  I 

* New  Orleans  Med.  and  Surg.  Journal,  Not.  1845. 


ACUTE  RHEUMATISM. 


307 


might  say  the  giving  it  up  in  despair,  by  some — should 
induce  us  to  congratulate  the  present  and  future  ages, 
on  the  success  attending  the  present  mode  of  treatment; 
which,  while  it  averts  or  relieves  such  a vast  amount  of 
human  suffering,  distress,  and  death,  adds  another  trophy 
to  the  healing  art,  and  is  well  calculated  also  to  advance 
the  reputation  of  the  medical  profession. 

In  plethoric  subjects,  at  the  commencement  of  the  at- 
tack, if  there  should  be  considerable  febrile  excitement, 
it  may  be  advisable  to  draw  from  eight  to  twenty  ounces 
of  blood  from  the  arm.  Soon  after  this  operation  is  over — 
or  even  in  cases  where  venesection  has  not  been  resorted 
to — give  a dose  composed  of  quinine,  from  eight  to  twelve 
or  fifteen  grains ; morphine,  from  one-third  to  half  a grain ; 
calomel  and  rhubarb,  each,  ten  grains.  Repeat  the  quin- 
ine in  doses  of  from  six  to  twelve  grains,  three  or  four  times 
a day,  till  the  disease  has  yielded;  then  continue  to  give  it 
in  from  three  to  five-grain  doses,  three  times  a day,  till 
the  health  of  the  patient  is  again  restored.  The  mor- 
phine, opium,  or  laudanum,  should  be  given  as  often  as 
occasion  requires,  for  the  relief  of  pain  or  restlessness. 

The  bowels  should  at  first  be  pretty  freely  evacuated ; 
after  which,  one  or  two  operations  a day  wall  be  suffi- 
cient; which  may  be  procured  by  extract  of  white  wal- 
nut, black  root,  rhubarb,  the  root  of  the  common  silk 
weed,  sulphur,  etc.  etc.  To  the  joints,  which  are 
principally  affected,  if  the  pain  be  severe,  it  may  be 
of  some  service  to  apply  opiate  lotions,  as  a strong  solu- 
tion or  infusion  of  Jamestown  -weed,  opium,  or  laudanum, 
camphor,  or  opodeldoc,  ointment  of  Jamestown  weed, 
opium,  poppies,  etc  ; the  frge  use  of  warm  water  over  the 
affected  joint,  or  the  firm  pressure  of  a flannel  bandage. 
These,  however,  should  only  be  looked  upon  in  the  light 
of  adjuvantia,  the  internal  use  of  the  quinine  being  the 
chief  reliance. 


308 


TYPHOID  PNEUMONIA. 


If  these  means  be  promptly  resorted  to,  we  shall  soon 
have  the  satisfaction  of  seeing  the  patient  well ; nor  will 
those  metastases,  translations,  or  migrations  of  the  local 
affections  of  the  joints,  to  the  heart,  stomach,  etc  , so  often 
occur;  indeed,  if  the  above  treatment  be  resorted  to  in  time, 
we  need  never  expect  these  occurrences ; and  when  they 
do  occur,  quinine,  opium,  and  calomel,  if  the  disease  has 
not  proceeded  too  far,  are  the  remedies  for  this  condition. 
Free  doses  of  quinine  should  be  regarded  as  the  princi- 
pal remedy.  If  the  patient  should  be  one  with  whom 
quinine  disagrees,  I would  advise  the  use  of  ferrocyanate 
of  quinia,  in  five-grain  or  larger  doses. 

In  conclusion,  it  may  be  proper  to  remark,  that  the 
practice  here  recommended  does  not  obtain  amongst  the 
profession  generally.  Some  southern  practitioners,  and 
a few7  European  physicians,  may  be  said  to  be  the  prin- 
cipal ones  initiated  into  this  new  and  successful  mode 
of  treating  acute  rheumatism. 


CHAPTER  XXI. 

TYPHOID  PNEUMONIA. 

# 

Nervous  pneumonia,  malarious  pneumonia,  or  acute 
cerebrospinal  irritation  with  pulmonary  congestion , I 
consider  names  more  applicable  to  this  form  of  disease 
than  typhoid  pneumonia.  By  some  it  has  been  termed 
malignant  pneumonia , and  i%some  localities  it  has  been 
called  winter  fever,  in  others,  bilious  pleurisy  ; and  in 
some  places,  in  which  it  has  been  ushered  in  by  a pro- 
tracted, very  distressing  chill,  sometimes  terminating 
fatally,  it  has  received  the  appellation  of  cold  plague.  In 


TYPHOID  PNEUMONIA. 


309 


consequence  of  the  severe  lancinating  pain  in  the  side, 
it  is  sometimes  called  by  the  country  people  side ■pleurisy . 

Though  this  disease  is  one  of  the  most  corrigible 
known  in  the  practice  of  medicine,  if  the  proper  treat- 
ment is  early  and  promptly  resorted  to,  I am  sorry  that 
truth  forces  me  to  say  that,  it  is,  even  at  present,  an  op- 
probrium to  the  profession.  It  prevails  most  commonly 
and  more  universally  in  the  latter  winter  and  early  spring 
months,  say  from  January  to  April,  or  even  May.  It, 
however,  may  occur,  though  rarely,  earlier  in  the  winter, 
or  in  the  summer  season,  especially  in  the  former,  as  it 
sometimes  prevails  to  some  extent  in  December,  under 
favorable  circumstances  for  its  development.  Like  in- 
termittent and  remittent  fevers,  it  sometimes  exhibits  the 
appearance  of  an  epidemic,  which  it  is  most  likely  to  do 
when  the  winter  and  spring  are  very  wet  and  variable. 
It  is  principally  confined  to  damp  or  swampy  situations, 
where  chills  and  fever  are  endemic. 

Though  Shakspeare  says  there  is  nothing  in  a name 
— and  essentially  there  is  not,  as  “ a rose  may  smell  as 
sweet  by  any  other  name”  — this  disease  is  a woful 
exception  to  the  remark ; for  its  name  ( typhoid  pneu- 
monia) has  induced  those  few  authors  who  have  no- 
ticed it,  to  associate  it  with  the  typhoid  pneumonia  of 
Ireland,  other  portions  of  Europe,  and  the  northern  por- 
tion of  our  own  country;  and  the  treatment  recommend- 
ed by  European  and  northern  authors,  in  the  form  of 
disease  observed  by  them,  whether  proper  or  not,  is  im- 
proper and  fatal  in  the  disease  under  consideration. — 
Also,  in  consequence  of  the  success  of  the  lancet,  tartar 
emetic,  and  calomel,  in  the  treatment  of  open,  acute  in- 
flammatory pneumonia  (and  indeed  this  treatment,  with 
some  modifications,  is  recommended  by  European  and 
our  northern  authors  in  typhoid  pneumonia),  it  appears 


310 


TYPHOID  PNEUMONIA. 


that  when  a disease  is  called  pneumonia,  these  articles  of 
the  materia  medica  are  at  once  associated  with  it  in  the 
minds  of  physicians;  and,  notwithstanding  hundreds 
and  thousands  succumb,  it  is  remarkable  what  an 
influence  is  exerted  on  practitioners  by  preconceived 
opinions,  and  by  European  and  northern  writers,  who 
know  little  or  nothing  of  the  affection  called  typhoid 
pneumonia,  occurring  in  the  southern  and  south-western 
States.  I rejoice  to  see  that  a few  practitioners  here  and 
there,  scattered  about  in  different  portions  of  the  South, 
are  beginning  to  appreciate,  to  some  extent,  the  nature 
of  this  malady;  and,  though  they  have  only  in  part,  as 
yet,  appreciated  the  proper  mode  of  treatment,  we  may 
hope,  ere  long,  to  see  this  subject  universally  understood, 
and  thousands  of  the  human  family  saved  from  suffering 
and  a premature  grave.  Having  learned  its  nature  and 
treatment  from  clinical  or  practical  observation  and  ex- 
perience, it  affords  me  much  gratification  to  have  this 
opportunity  of  making  it  generally  known. 

It  is  well  known  that  this  disease,  in  some  years,  is 
more  particularly  prevalent  and  fatal  amongst  the  ne- 
groes; and  it  has  been  observed  that  they  succumb  more 
readily  to  it  than  the  white  population.  It  most  fre- 
quently attacks  adults,  or  those  over  twelve  or  fifteen 
years  of  age;  though  younger  persons  are  occasionally 
attacked  wTith  it,  young  children  being  very  seldom,  if 
ever,  the  subjects  of  it.  It  is  sometimes  quite  fatal,  es- 
pecially when  it  appears  as  an  epidemic,  or  endemico- 
epidemic,  amongst  very  old  persons.  Sometimes  it  makes 
its  appearance  as  an  epidemic  in  certain  districts,  where 
it  was  previously  scarcely  known.  This  was  the  case 
at  Hillsboro  (Middle  Tennessee),  and  the  surrounding 
country,  in  the  winter  and  spring  of  1847,  where  it 
was  quite  fatal,  in  consequence,  as  is  common  elsewhere, 
of  the  improper  treatment  adopted;  or  perhaps  I should 


TYPHOID  PNEUMONIA. 


311 


rather  say,  the  want  of  prompt  and  proper  treatment. 
It  is  more  or  less  common  in  the  winter  and  spring  in 
many  malarious  districts,  and  occasionally  appearing 
in  some  that  are  but  slightly  so,  being  comparatively 
healthy.  For  a few  seasons  past,  it  has  been  more  or 
less  prevalent  in  the  Tennessee  river  valley,  in  North 
Alabama.  I have  been  informed  that  in  1846  and  ’7 
(the  latter  part  of  winter  and  early  spring  months,  as 
usual,  being  the  time  of  its  prevalence),  it  was  extremely 
fatal  at  Decatur  and  its  environs,  some  150  or  more  per- 
sons falling  victims  to  it. 

; v . { ' . ‘ ; - 'L/ 

Description. — Typhoid  pneumonia  makes  its  appear- 
ance in  two  ways : First.  According  to  the  author’s 
observation,  it  more  frequently  manifests  itself  in  the  form 
of,  or  analogous  to,  an  ordinary  catarrh,  “ bad  cold,”  or 
influenza  ; such  as  hoarseness,  a short,  dry,  hacking 
cough,  with  usually  but  little,  or  not  free,  expectoration, 
which  is  of  a whitish  appearance,  rather  dense  or  semi- 
fluid, and  thrown  off  in  small  quantities  at  a time,  which 
adhere  together.  Perhaps  there  is  some  slight,  or  more 
or  less  severe,  headache  ; a general  sensation  of  dullness 
or  uncomfortableness,  appetite  more  or  less  impaired, 
with  some  slight  feverishness  once  a day.  There 
is  more  or  less  pain  in  some  portion  of  the  chest,  or  in 
the  side,  which  is  increased  by  the  cough.  This  pain, 
according  to  the  author’s  experience,  is  nearly  always  in 
the  right  side  of  the  chest,  in  the  neighborhood  of  the 
right  nipple,  usually  about  tw*o  inches,  less  or  more,  to 
the  right  of  it,  either  below  or  above,  and  rather  towards 
the  spine,  apparently  a kind  of  acute,  intercostal  neu- 
ralgia. This  pain  is  more  or  less  sharp  and  cutting, 
usually  attended  with  some  slight  stricture  of  the  chest. 

The  above  condition  may  last  for  several  days,  a week, 
or  more,  till  the  individual  either  begins  to  convalesce, 


312 


TYPHOID  PNEUMONIA. 


or,  what  is  perhaps  much  more  common,  suddenly  be- 
comes much  worse,  probably  has  a chill  of  greater  or  less 
severity,  when  the  symptoms  become  identical  or  analo- 
gous to  the 

Second  Form  of  Attack. — This  form,  perhaps  preceded 
for  a time  by  a dry,  hacking  cough,  with  some  pain  in 
the  side,  which  is  increased  by  the  cough,  makes  its  ap- 
pearance pretty  much  like  an  attack  of  intermittent  fever, 
the  chill  usually  being  more  severe,  with  intense,  almost 
insupporable,  cutting  pain,  which  appears  to  be  on  the 
outside  of  the  ribs,  or  in  the  intercostal  spaces ; slight 
pressure  causing  it  to  be  very  excruciating,  commonly  in 
the  right  side,  as  noticed  above;  and  which  is  rendered 
much  more  severe  and  troublesome  by  the  frequent 
hacking  cough.  Respiration  is  short,  irregular,  and 
frequent,  with  an  occasional  deep  sigh;  eyes  usually 
watery,  and  somewhat  injected  ; features,  perhaps,  some- 
what contracted,  and  commonly  more  or  less  of  a crim- 
son hue,  without  that  fullness  they  present  in  inflam- 
matory fever ; at  times,  however,  they  are  rather  pale. 
In  some  cases  the  tongue  is  clean,  and  redder  than 
natural ; in  others,  covered  with  a thin,  whitish  fur. 
There  is  usually  considerable  anxiety  and  restlessness  ; 
more  or  less  headache,  and,  in  some  cases,  pain  in  the 
back  and  extremities;  nausea,  unpleasant  or  heavy  sen- 
sation in  the  stomach,  or  gastric  distress,  and  vomiting. 
The  pulse  is  small,  more  or  less  increased  in  frequency, 
its  powers  of  resistance  very  slight,  yielding  to  very  gen- 
tle pressure.  The  prostration  of  the  patient  is  usually 
considerable ; the  spirits  more  or  less  dejected  ; frequently 
some  degree  of  delirium. 

In  those  cases  which  are  neglected  for  several  days,  or 
the  usual  improper  antiphlogistic  treatment  adopted, 
rusty  sputa  often  soon  appear ; but  in  nearly  all  in- 
stances (indeed  all,  so  far  as  the  author's  experience  ex- 


TYPHOID  PNEUMONIA— DESCRIPTION. 


313 


tends)  in  which  the  proper  treatment  is  early  and 
promptly  resorted  to,  they  are  not  seen  at  all.  After  the 
chill  is  over,  or  even  during  the  chilly  sensations,  and 
while  the  extremities  are  cool,  the  skin  is  apt  to  be  dry, 
and  about  the  trunk  warm  ; but  as  the  disease  progresses, 
the  temperature  of  the  skin  often  varies,  sometimes 
being  warm  and  dry,  of  a natural  temperature,  cool 
and  dry,  or  cool  and  moist,  or  even  clammy.  After 
the  chilly  condition  passes  off,  some  degree  of  reaction 
comes  on ; the  general  surface  becomes  warm  and  dry, 
with,  perhaps,  some  occasional  moisture  about  the  tem- 
ples; the  pulse  becomes  more  full  and  resisting,  but  only 
so  to  a moderate  degree.  Subsequently,  this  febrile 
reaction  may  be  observed  to  occur  once  a day,  generally 
in  the  afternoon  ; preceded,  in  the  forenoon  usually,  by 
coolness  of  the  extremities ; during  this  reaction,  the 
cheeks  are  commonly  somewhat  flushed,  in  some  in- 
stances one  side  being  more  so  than  the  other. 

In  some  cases,  the  pain  in  the  side  is  scarcely  percep- 
tible; but  the  pulmonary  congestion,  oppression,  or  un- 
easiness in  the  chest,  and  difficult  respiration,  are  consider- 
able. These  cases  are  attended  with  great  prostration  ; 
a clammy  sweat  often  ensues;  and,  if  the  patient  does  not 
receive  prompt  and  proper  attention,  the  prostration  and 
dyspnoea  become  more  and  more  serious,  and  death  may 
be  reasonably  feared. 

With  regard  to  the  pain  in  the  side,  which  we  have 
heretofore  observed  is  usually  in  the  right  side,  by  re- 
questing the  patient  to  place  his  hand  on  the  particular 
place  where  the  intense  pain  is,  especially  soon  after  the 
attack,  he  will  often  feel  about  for  some  time,  and  manifest 
much  difficulty  in  finding  any  particular  spot  where  it 
is ; in  other  words,  it  appears  to  be  more  or  less  dif- 
fused about  the  region  where  it  is  felt.  In  other  cases, 
21 


314 


TYPHOID  PNEUMONIA— CAUSES. 


the  pain  is  circumscribed  and  located,  occupying  a very 
small  spot,  perhaps  not  larger  than  a half  dollar. 

Duration. — If  the  proper  treatment  is  adopted  soon 
after  the  attack,  it  may  be  arrested  in  a day  or  two,  even 
the  severer  attacks ; or  it  may  require  several  days,  a 
week,  or  more.  When  a case  has  lasted  a few  days  be- 
fore the  proper  means  have  been  resorted  to,  it  may  re- 
quire from  seven  or  eight  to  twelve  days  before  convales- 
ence  will  be  perfect;  or  the  case  may  be  protracted  to 
three  or  four  weeks,  or  longer,  and  then  recover,  or  die. 

Causes. — I have  already  remarked  that  nervous  pneu- 
monia is  almost  entirely  confined  to  the  latter  winter  and 
spring  months  (March  and  April),  and  more  especially 
wdien  these  are  wet  and  variable  in  their  temperature. 
I also  remarked  that  it  occurred  in  those  damp  or 
swampy  situations  where  ague  is  endemic.  It  has  even 
been  observed  in  New  England,  to  be  more  violent  and 
fatal  in  swamp}^  regions,  about  bogs  and  millponds, 
where  intermittents  were  common  ; and  yet  it  seems  that, 
notwithstanding  this  peculiarity,  authors  continue  to 
confound  it  with  the  old  typhoid  pneumonia,  febris  pe- 
techialis  (spotted  fever),  or  pestilential  typhus,  etc.  Per- 
haps the  same  cause  or  causes  which  produce  intermittent 
fever,  modified  by  the  season  of  the  year,  may,  with 
propriety,  be  regarded  as  the  cause  of  the  disease  under 
consideration.  When  it  appears  as  an  epidemic,  it  is 
commonly  regarded  as  being,  at  least  to  some  extent, 
dependent  on,  or  referable  to,  some  peculiarity  of  the 
atmosphere.  Everything  which  has  a tendency  to  de- 
bilitate the  system,  renders  it  more  liable  to  be  attacked 
with  this  disease ; hence,  those  who  have  had  the  chills, 
remittent  or  congestive  fever,  the  previous  summer  or 
autumn,  are  more  likely  to  suffer  with  it.  Exposure 


TYPHOID  PNEUMONIA— PATHOLOGY. 


315 


in  cool  or  cold  wet  weather,  and  especially  standing 
or  walking  for  some  time  on  cold,  damp,  or  wet,  muddy 
ground,  in  districts,  and  in  seasons  of  the  year  when 
it  usually  prevails,  are  very  likely  to  produce  it.  Un- 
der these  circumstances,  we  need  not  be  surprised  that 
it  is  sometimes  more  common  amongst  the  negroes, 
especially  in  the  rich  prairie  lands,  or  low,  swampy 
situations.  Insufficient  food  and  clothing,  protracted, 
exhausting  labor,  or  indeed  anything  else  which  has 
a tendency  to  weaken  the  system,  may  render  it  more 
liable  to  this  disease. 

Pathology.— -It  would  seem  that  there  can  be  no 
hesitation  in  referring  the  chief  primary  morbid  impres- 
sion to  the  cerebro-spinal  region,  to  those  parts  from 
which  nerves  arise  that  are  distributed  to  the  thorax  and 
its  contents ; these  latter,  therefore,  not  receiving  a suffi- 
cient amount  of  nervous  influence  to  carry  on  their  func- 
tions normally,  become  congested,  engorged  ; which,  if 
not  soon  relieved,  is  succeeded  by  a low  grade  of  inflam- 
mation. The  lungs  are  not  the  only  parts  which  suffer ; 
as  the  pleura,  heart,  and  even  the  stomach,  also  partici- 
pate, or  suffer,  from  the  morbid  impression  made  in  the 
cerebro-spinal  region,  from  whence  the  nerves  originate 
that  supply  them.  As  we  might  expect,  from  the  inti- 
mate connection  of  the  spinal  and  organic  systems  of 
nerves,  the  functions  of  the  organs  over  which  the  latter 
principally  preside  become  impaired,  and  these  organs, 
consequently,  also  participate  in  the  morbid  condition. 
So  the  reader  will  perceive  that,  so  far  as  the  lungs  are 
concerned,  it  is  not  primarily  a pneumonia , or  inflamma- 
tion of  the  lungs,  but  a congestion , with  impaired  func- 
tions. The  pleura  and  heart  also  at  the  same  time  suffer 
from  congestion  ; and  as  the  disease  progresses,  like  the 
lungs,  may  suffer  from  a low  grade  of  inflammation  and 


316  TYPHOID  PNEUMONIA— PHYSICAL  SIGNS— TREATMENT. 

effusion.  The  greater  the  primary  morbid  condition  of 
the  cerebro-spinal  axis,  and  the  implication  of  the  or- 
ganic system  of  nerves,  the  greater  will  be  the  affection 
of  the  thoracic  viscera,  and  the  distress  and  prostration  of 
the  patient.  If  the  disease  lasts  for  some  time  (which 
it  commonly  does  when  treated  in  the  usual  improper 
manner,  with  tartar  emetic,  calomel,  &c.),  the  lungs 
are  apt  to  become  hepatized , or  solidified,  of  the  ap- 
pearance and  consistence  of  the  liver.  As  this  morbid 
condition  of  the  lungs  progresses  from  the  lower  to 
the  upper  portions,  the  air  ceases  to  penetrate  these  ; 
hence  respiration  is  imperfectly  performed,  and  increased 
in  frequency.  The  bowels  are,  in  most  instances,  easily 
irritated  and  inflamed,  to  an  injurious  degree,  by  irri- 
tating or  active  cathartics,  and  tartar  emetic. 

Physical  Signs. — Soon  after  the  attack,  the  vesicular 
or  respiratory  murmur  will  be  feeble,  then  scarcely  audi- 
ble, and,  as  the  lungs  become  more  and  more  engorged, 
as  the  disease  progresses,  the  vesicular  murmur  frequently 
disappears  entirely  from  a large  portion  of  the  lower  lobes 
of  the  lungs.  Bronchophony  also  indicates  this  condition 
of  the  lungs,  as  does  also  the  thoracic  vibration,*  by 
placing  the  hand  on  the  chest,  and  requesting  the  patient 
to  speak  or  cough.  Percussion  elicits  a dull  sound, 
which  becomes  more  and  more  so  as  the  engorgement 
and  liepitization  of  the  lungs  increase.  I believe  sub- 
crepitant or  mucous  rhonchi  (rattle)  may  most  commonly 
be  heard  in  the  region  of  the  larger  bronchia,  near  the 
bifurcation  of  the  trachea. 

Treatment. — The  treatment  requires  some  modifica- 
tions, so  as  to  adapt  it  to  the  mode  and  severity  of  the 


* See  pages  112 — 114. 


TYPHOID  PNEUMONIA— TREATMENT. 


317 


attack  and  the  stage  of  the  disease.  I will  here  mention, 
however,  that  quinine  and  opium  are  the  principal  reme- 
dies to  be  relied  upon ; and  the  earlier  and  more  promptly 
they  are  given,  the  sooner  will  the  disease  be  arrested. 

To  commence  the  treatment  in  the  first  form  of 
attack  noticed  above  (analogous  to  a “bad  cold”),  and 
before  the  individual  is  “ taken  down,”  give  a dose  com- 
posed of  quinine  (four  or  five  grains),  laudanum  (twenty- 
five  or  thirty  drops),  ipecac,  (two  grains),  and  a cathartic 
or  aperient;  for  which  latter  purpose,  fifteen  or  twenty 
grains  of  rhubarb,  or  eight  or  ten  grains  of  jalap,  or  a 
little  extract  of  white  walnut,  will  answer.  The  quinine 
and  ipecac,  should  be  repeated  three  or  four  times  a day. 
with  the  addition  to  each  dose,  if  necessary,  from  forty  to 
sixty  drops  of  paregoric,  to  allay  or  control  cough  and 
pain ; or,  a teaspoonful  or  more  may  be  taken  at  once, 
for  this  purpose.  If  necessary  to  open  the  bowels, 
the  cathartics  may  be  given  every  night.  If  there 
should  be  any  attendant  feverishness  or  excitement, 
six  or  eight  grains  of  calomel  may  be  added  to  the  rhu- 
barb or  jalap,  but  it  should  not  be  given  more  than  once 
or  twice,  and,  if  given  the  second  time,  after  an  interval 
of  twenty-four  or  forty -eight  hours.  If  the  above  means 
should  not  control  the  pain  and  cough,  laudanum  may  be 
given  at  any  time  for  this  purpose,  still  continuing  the 
other  remedies.  Instead  of  mixing  paregoric  with  each 
dose  of  quinine  and  ipecac.,  as  above,  a very  good  mix- 
ture for  this  purpose  may  be  made  as  follows,  and  taken 
either  with  the  quinine,  or  quinine  and  ipecacuanha,  or 
alone,  at  any  other  time  : — 

R.  Paregoric  two  ounces; 

Syrup  of  squills  one  ounce  ; 

Tincture  of  puccoon  root  one  ounce  ; 

Sulphate  of  zinc  fifteen  grains  ; 

Water  four  drachms. 

Dissolve  the  sulphate  of  zinc  (white  vitriol)  in  the 


318  TYPHOID  PNEUMONIA — TREATMENT. 

water ; then  add  the  other  ingredients,  and  shake  them 
all  together ; dose,  from  a teaspoonful  to  a dessertspoon- 
ful, three  or  four  times  a day.  If  the  case  is  mild,  this 
mixture  alone  may  be  sufficient  to  effect  a cure ; but  in 
such  cases  it  will  be  necessary  to  give  an  aperient  at 
night,  as  occasion  requires,  to  which  four  or  five  grains 
of  quinine  may  be  profitably  added.  Indeed,  unless  the 
case  is  very  mild,  it  will  be  advisable  to  take  the  quinine 
three  or  four  times  a day  ; mixed,  as  before  advised,  with 
the  above  syrup  or  mixture. 

It  is  often  the  case  that  the  milder  symptoms,  above 
noticed,  are  neglected  till  the  case  speedily  assumes  a 
violent  form,  analogous  to  a sudden  primary  attack,  with 
little  or  no  previous  warning.  We  have  already  seen 
that  when  this  is  the  case,  the  person  attacked  usually 
has  a severe,  distressing,  and  more  or  less  protracted 
chill,  frequently  attended  with  an  intense,  cutting,  almost 
insupportable  pain,  as  heretofore  observed,  usually  in  the 
right  side,  which  is  greatly  increased  by  the  attendant 
cough  ; or  there  is  considerable  stricture  and  oppression 
in  the  chest,  with  less  or  more  uneasiness,  heaviness,  or 
pain  in  the  stomach.  Commonly,  an  emetic  should  not 
be  given,  unless  the  patient  is  attacked  soon  after  eating 
a hearty  meal,  in  which  case  ipecac,  should  be  taken. 
Soon  after  the  emetic  has  caused  the  contents  of  the  sto- 
mach to  be  thrown  up — or,  if  it  has  not  been  necessary  to 
give  an  emetic — a dose  composed  as  follows  should  imme- 
diately be  exhibited  : — 

R . Laudanum  from  forty-five  drops  to  a teaspoonful ; 

Sulphate  of  quinine  “ eight  to  ten  grains  ; 

Calomel  “ eight  to  twelve  grains ; 

Jalap  “ sis  to  eight  grains.  Mis. 


If,  on  account  of  the  irritability  of  the  stomach,  the  above 
dose  be  thrown  up,  it  should  be  repeated.  If  the  chill 


TYPHOID  PNEUMONIA— TREATMENT. 


319 


be  severe,  a teaspoonful  or  two  of  sulphuric  ether  may 
be  profitably  given ; and  two  or  three  teaspoonfuls  pour- 
ed on  a handkerchief,  held  to  the  nose  and  mouth, 
and  inhaled,  will  give  almost  immediate  relief.  If,  in 
the  course  of  half  an  hour,  or  an  hour,  relief  should  not 
be  obtained,  the  laudanum  ought  to  be  repeated  in  a 
dose  of  from  thirty  to  fifty  drops — to  an  adult.  If  the 
first  dose  does  not  give  relief  (which,  however,  it  rarely 
fails  to  do),  the  ether,  or  this  last  dose  of  laudanum 
will,  almost  invariably.  The  patient  should  be  covered 
with  two  or  three  blankets;  and,  if  he  desire  it,  hot 
rocks  or  irons  should  be  applied  to  his  feet. 

After  the  chill  passes  off,  as  before  observed,  there  is 
some  degree  of  reaction,  perhaps  amounting  to  a febrile 
condition,  with  a warm,  dry,  harsh  skin.  When  this 
occurs,  from  half  a dozen  to  a dozen  ears  of  corn,  just 
taken  out  of  hot  water,  should  be  placed  around  the  body 
and  limbs  of  the  patient,  to  soften  or  moisten  the  skin 
and  induce  perspiration ; this  usually  has  an  excellent 
effect,  not  only  in  producing  perspiration,  but  in  contri- 
buting to  the  relief  of  the  pain  and  thoracic  distress,  as 
well  as  by  tending  to  relieve  the  febrile  condition.  If  the 
patient  desire  it,  he  should  be  allowed  small  quantities 
of  cold  water,  frequently  repeated.  This  disease  having 
obtained  the  appellation  of  Pneumonia,  now  is  the  time 
that  practitioners  resort  to  general  and  topical  blood- 
letting, the  frequently  repeated  exhibition  of  tartar  eme- 
tic, calomel,  &c. ; all  of  which  co-operate  with  the 
disease  in  prostrating  if  not  destroying  the  patient.  In 
many  cases  the  bowels  are  thus  irritated  and  inflamed, 
and  purging  and  griping  brought  about;  the  rusta  sputa 
are  made  to  appear,  which  might  never  have  occurred, 
if  the  proper  course  of  treatment  had  been  adopted. 
Some  practitioners,  who  are  not  often  willing  to  resort  to 


320 


TYPHOID  PNEUMONIA— TREATMENT. 


venesection,  are  very  fond  of  cupping  freely  over  the  seat 
of  pain  and  different  parts  of  the  chest;  as  they  say  it 
affords  relief,  and  reduces  the  frequency  of  the  pulse.  I 
do  not  deny  that  cupping,  in  this  manner,  may  afford 
temporary  relief — from  the  shock  or  excitement  this  bar- 
barous custom  gives  to  the  nervous  system,  but  I believe 
it  is  illusory ; as  in  the  case  of  one  with  the  toothache, 
who  goes  to  a doctor’s  office  to  get  the  troublesome 
tooth  extracted ; when  he  arrives  there,  frequently  the 
pain  has  entirely,  or  in  a great  measure,  ceased ; 
but,  if  he  returns  home  without  having  it  extracted, 
the  cause  of  the  pain  not  having  been  removed,  the  ach- 
ing soon  returns.  The  antiphlogistic  and  frequently 
fatal  treatment  here  alluded  to,  is  the-  one  which  at  pre- 
sent is  adopted  by  the  generality  of  the  medical  world, 
with  a very  few  exceptions ; and  when  this  is  the  case, 
need  we  be  surprised  that,  in  its  fatality,  typhoid  pneu- 
monia has  been  classed  with  Asiatic  cholera,  the  plague, 
yellow  fever,  or  typhus  gravior  ? or  as  being,  in  some  in- 
stances, even  more  fatal  than  these?  The  author  is  of 
opinion  that,  if  the  proper  treatment  was  adopted  in  time, 
death  would  be  very  rare  as  the  result  of  this  disease ; 
as,  from  the  mode  he  adopts,  he  has  not  lost  a single 
case.  In  the  more  insidious  attacks,  persons  in  the 
country  sometimes  neglect  to  attend  to  it  in  time,  or 
fail  to  call  in  a physician  till  it  has  so  far  advanced 
that  the  lungs  have  become  so  permanently  engorged, 
perhaps  to  some  extent  hepatized,  and  their  functions 
so  much  interrupted  or  impaired,  that  it  is  no  doubt 
impossible,  in  many  such  cases,  for  the  best  directed 
treatment  to  succeed.  In  the  latter  stages,  when  the 
system  is  greatly  prostrated,  and  the  lungs  in  the  con- 
dition above  noticed,  authors  recommend  a combina- 
tion of  stimulants,  as  ammonia,  with  calomel  and  tar- 


TYPHOID  PNEUMONIA— TREATMENT. 


321 


tar  emetic;  this  the  author  considers  very  improper, 
especially  so  far  as  the  tartar  emetic  is  concerned,  as 
well  as  the  too  liberal  use  of  calomel. 

After  this  digression,  I will  remark  that,  in  some  cases 
where  the  individual  is  of  a sanguine  temperament,  is 
very  stout  and  vigorous,  and  more  especially  when  there 
is  considerable  determination  to  the  brain,  with  flushed 
cheeks,  attended  with  some  degree  of  febrile  excitement, 
hot,  dry  skin,  pain  in  the  head,  a venesection  in  the 
early  stages  of  the  disease  may  be  demanded ; but  it 
should  not  usually  be  resorted  to,  especially  if  the  skin 
or  extremities  are  cool,  feeble  pulse,  &c.,  even  though 
there  is  pain  in  the  head ; as,  under  the  latter  circum- 
stances, it  is  most  likely  to  be  of  a nervous  nature,  and 
not  the  result  of  inflammatory  action  in  the  brain. — 
Usually,  venesection  should  be  resolved  upon  with  great 
caution,  as  fatal  prostration  might  be  induced  by  it ; 
when,  however,  it  is  thought  advisable,  quinine  and 
morphine  should  also  be  freely  given,  so  as  to  sup- 
port the  vital  powers  and  prevent  prostration.  If  the 
excitement  is  not  great,  camphor,  with  the  quinine, 
may  answer  a good  purpose.  If  there  should  be  much 
determination  to  the  head,  cold  water  applied  to  it,  and  to 
the  back  of  the  neck,  will  probably  afford  much  relief. 
Cases  of  this  kind  also  more  imperatively  demand  a ca- 
thartic or  two,  as  of  calomel  and  jalap,  at  the  onset  of  the 
disease;  after  which,  cathartics  should  not  be  given;  or, 
if  thought  necessary,  with  a wise  caution;  though  an 
occasional  aperient  may  be  useful  It  is  extremely  rare, 
that  a case  occurs  in  this  region  of  country  which  re- 
quires venesection;  but  I am  of  opinion  that,  farther 
North,  it  may  more  frequently  be  demanded  and  resort- 
ed to  with  benefit,  at  the  onset  of  the  disease ; though 
perhaps,  even  there,  it  is  too  frequently  practiced. 

But  to  return  to  where  we  left  our  patient,  after  fol- 


322 


TYPHOID  PNEUMONIA— TREATMENT. 


lowing  him  through  his  chill  or  rigor,  and  the  period 
of  temporary  febrile  reaction,  which  latter  is  usually 
slight,  the  pulse  being  commonly  soft  and  yielding. 
After  this  period,  quinine,  in  from  four  to  six  grain 
doses,  should  be  given  three  or  four  times  a day,  com- 
bined with  a dose  of  the  syrup  or  mixture  before  noticed, 
on  page  317.  The  ears  of  corn,  just  taken  out  of  hot 
water,  should  be  applied  around  the  body  occasionally, 
if  the  skin  becomes  harsh,  warmer  than  natural,  or 
even  of  the  natural  temperature,  if  it  is  dry,  which  is  not 
unfrequently  the  case — there  being  but  little,  moderate, 
or  no  perceptible  alteration  of  the  temperature  of  the  sur- 
face for  several  days,  or  during  the  whole  course  of  the 
disease,  in  many  cases.  Whenever  there  is  dry  skin — 
accompanied  or  not  with  pain  in  the  side  or  chest,  or 
thoracic  distress,  as  heretofore  observed — the  hot  corn 
affords  great  relief.  If  there  be  much  pain  at  any 
time,  it  should  be  controlled  by  opiates;  as  opium,  laud- 
anum, or  morphine;  and  in  these  cases  it  is  better  to 
give  an  ample  dose  at  once,  than  to  give  small  ones,  fre- 
quently repeated.  It  will  usually  be  sufficient  to  pro- 
cure one  cr  two  operations  from  the  bowels  every  thirty- 
six  hours;  this  may  be  done  with  jalap  and  rhubarb;  or, 
if  the  pain  in  the  side  should  be  located,  remaining  in 
one  place,  and  greatly  aggravated  by  pressure,  six  or 
eight  grains  of  calomel  should  be  added  to  as  much  jalap. 
If  the  skin  is  warm,  dry,  and  harsh,  jalap,  with  the  other 
remedies,  is  preferable  to  many  cathartics  or  aperients, 
because  it  acts  so  as  to  prodilce  perspiration.  The 
amount  of  opiates  required,  prevents  these  cathartics 
(which  are  here  given  as  aperients,  &c.)  from  acting 
unpleasantly  on  the  bowels;  if,  however,  they  should 
produce  too  much  irritation,  inflammation,  griping,  and 
purging  (which,  however,  they  rarely  or  never  do,  given 
as  directed  above),  these  effects  should  be  controlled  by 


TYPHOID  PNEUMONIA— TREATMENT. 


323 


laudanum  or  paregoric.  According  to  the  present  mode 
of  practice  among  most  physicians,  it  is  often  the  case 
that  inflammation  of  the  bowels  and  fatal  prostration  is 
induced,  which  should  be  avoided. 

In  the  latter  stages  of  this  disease,  and  even  some- 
times in  the  earlier,  some  are  in  the  habit  of  covering  a 
large  portion  of  the  chest  with  blisters ; but  I am  of  the 
opinion  that  this  barbarous  custom  is  generally  not  only 
useless,  but  in  many  cases,  perhaps  a large  majority  of 
them,  is  well  calculated  to  do  positive  harm,  from  the 
irritability,  distress,  and  increased  debility  which  it  pro- 
duces. In  some  cases,  however,  a blister  over  the  seat 
of  pain,  between  the  shoulders,  or  on  the  back  of  the 
neck,  may  afford  some  relief ; but  a cataplasm  of  mus- 
tard and  flour  is  perhaps  preferable  in  all  cases;  or 
the  application  of  warm  spirits  turpentine  over  these 
regions ; together  with  the  hot  ears  of  corn,  before  men- 
tioned, applied  about  the  patient,  who  should  be  covered 
with  a blanket  next  the  body,  and  one  or  two  quilts,  or 
other  bed-clothing,  so  as  to  make  him  comfortably  warm, 
and  induce  moisture  of  the  skin,  or  perspiration. 

As  the  disease  subsides,  the  quinine  should  be  taken 
in  smaller  doses,  say  two  or  three  grains,  three  times  a 
day,  till  convalescence  is  pretty  well  established,  after 
which  twice  a day  may  suffice ; but  the  cough  mixture, 
for  which  a formula  has  heretofore  been  given,  ought  to 
be  continued,  three  times  a day,  as  long  as  the  cough  re- 
mains ; the  dose,  however,  may  be  somewhat  reduced  as 
the  cough  yields.  During  convalescence,  if  the  system 
be  much  relaxed  and  debilitated,  with  occasional  colli- 
quative sweats,  some  of  the  ferruginous  preparations 
should  be  taken  two  or  three  times  a day,  either  alone  or 
with  a little  quinine;  say,  for  instance,  ten  grains  of  sub- 
carbonate of  iron,  or  three  grains  of  copperas,  with  two 
or  three  grains  of  quinine,  and  the  addition  of  three  grains 


324 


TYPHOID  PNEUMONIA— TREATMENT. 


of  pulverized  cayenne  pepper,  or  six  or  eight  grains  of 
pulverized  cinnamon.  For  this  purpose,  the  formula 
given  on  page  168,  when  treating  of  leucorrhoea,  is  also 
well  adapted. 

If  a case  of  typhoid  pneumonia  be  treated  inefficiently, 
so  that  hepitization  of  the  lungs  takes  place,  in  addition 
to  the  treatment  recommended  above,  five  or  six  grains 
of  blue  mass,  or  three  or  four  grains  of  calomel,  even- 
night,  may  be  of  service ; taking  care,  however,  to  sus- 
pend the  mercurial  before  salivation  is  induced  ; nor  is 
it  commonly  advisable  to  continue  its  use  for  a longer 
time  than  six  or  eight  days. 

The  diet  should  be  moderately  nourishing,  of  easy  di- 
gestion, and  taken  in  moderate  quantities,  principally 
consulting  the  inclinations  of  the  patient;  taking  care, 
however,  not  to  let  him  eat  anything  that  would  in  all 
probability  prove  injurious;  nor  should  he  be  allowed  to 
eat  too  much  at  once,  but  gradually  improve  his  diet  as 
convalescence  becomes  more  and  more  perfect. 

If  the  patient  has  been  much  debilitated,  it  ma}'  be 
advisable  to  wear  flannel  next  the  skin  the  remainder 
of  the  season,  or  till  warm  weather ; which  is  more  impe- 
rative if  his  pursuits  require  exposure  to  the  weather. 

As  some  of  my  professional  brethren  may  be  reluc- 
tant to  embrace  the  foregoing  views  in  relation  to  this 
disease,  I make  the  following  quotations,  which  are  in 
part  corroborative  of  the  above,  in  order  to  convince 
them  that  they  are  orthodox.  The  following  appears  in 
the  New  Orleans  Medical  and  Surgical  Journal: — 

“Parish of  St.  Mary’s,  19th  February,  1S47. 

11  Messrs.  Editors:  Since  the  1st  of  January,  the 
weather,  for  the  most  part,  has  been  extremely  unplea- 
sant. W e have  had  frequent  and  excessive  rains ; the 


TYPHOID  PNEUMONIA— TREATMENT. 


325 


changes  of  temperature  have  been  sudden  and  extreme 
— we  have  had  much  severe  cold  weather — more  so  than 
any  I have  experienced  during  a residence  of  ten  years 
in  this  State.  The  orange  trees  have  sustained  much 
injury.  A great  mortality  has  prevailed  among  the  cattle 
throughout  the  country,  arising  from  disease,  exposure  to 
the  weather,  and  scarcity  of  food. 

“As  a consequence  of  the  unfavorable  weather,  ca- 
tarrhs, accompanied  with  more  or  less  febrile  excite- 
ment, have  been  universal  — few  have  escaped.  An 
epidemic  pneumonia  has  been  prevailing,  and  still  con- 
tinues, in  my  neighborhood.  Negroes  are  the  principal 
subjects.  I have  met  with  but  two  or  three  cases  among 
the  whites ; many  of  the  cases  have  early  assumed  a ty- 
phoid appearance.  In  some  of  the  cases,  extensive 
hepitization  of  one  lung  was  found  to  exist  when  the 
cases  first  came  under  observation.  Some  plantations 
have  suffered  much  more  than  others;  on  one  plantation 
eleven  cases  occurred,  most  of  them  of  a severe  form. 

“ Since  the  1 st  of  January,  I have  treated  about  twenty- 
three  cases  ; three  deaths  have  thus  far  occurred;  one,  an 
old  gentleman  of  60,  and  two  negro  boys.  I have  seve- 
ral cases  now  under  treatment,  and  cannot  now  predict 
their  issue.  Most  of  the  cases  I have  seen,  have  been 
accompanied  by  great  gastric  irritability,  so  much  so  as 
entirely  to  forbid  the  use  of  the  tartar  emetic.  In  its 
treatment,  I have  derived  the  greatest  advantage  from 
the  use  of  quinine.  In  the  management  of  this  disease, 
I consider  no  remedy  equal  to  this.  In  many  cases,  it 
acted  like  a charm,  in  lessening  the  frequency  of  the 
pulse,  in  diminishing  the  number  of  respirations,  and 
sustaining  the  vital  powers.  Two  or  three  of  the  first 
cases,  in  which  I trusted  too  long  to  the  antiphlogistic 
treatment,  succumbed  ; as  soon  as  I made  free  use  of 
quinine,  conjoined  with  mercurials  and  opiates,  the  sue- 


326 


DIARRHCE  A AND  DYSENTERY. 


ceeding  cases  assumed  a favorable  aspect.  In  all  cases, 
where  I saw  the  patient  in  season,  the  treatment  was 
commenced  by  a copious  bleeding.  I have  given  the 
quinine,  in  doses  of  five  grains,  every  four  or  six  hours, 
and  I attribute  the  recovery  of  several  of  my  patients 
solely  to  its  use.  J.  B.  D.” 

Dr.  Jones,  of  Irwington,  Georgia,  writes  as  follows  to 
the  Southern  Medical  and  Surgical  Journal ',  dated  Feb., 
1848 : “ I am  now  very  busily  engaged  in  treating  an 
epidemic  pneumonia,  which  is  prevailing  extensively  in 
this  and  the  counties  west  of  this  place.  There  is  some- 
thing particularly  interesting  in  the  history  of  the  disease, 
but  it  is  impossible  for  me  to  give  it  to  you  now.  It  is 
confined  entirely  to  the  districts  and  water  courses  where 
intermittent  fever  is  most  prevalent  during  autumn. 

“ The  attack  is  sudden  and  violent,  with  great  pros- 
tration of  strength;  rapid,  feeble,  and  irregular  pulse; 
the  peculiar  rusty  sputa  appear  in  a few  hours.  It  will 
not  bear  well  general  depletion  ; large  doses  of  quinine 
give  almost  certain  relief.” 


CHAPTER  XXII 

DIARRIKEA  AND  DYSENTERY. 

Djarrhcea  and  Dysentery  are  commonly  treated  of 
by  authors  separately  ; but,  considering  them  identical, 
with  the  exception  that  dysentery  is  a severer  form  of 
diarrhoea,  I will  treat  of  them  under  the  same  head. 

Diarrhoea , lax , or  looseness  of  the  bowels , is  commonly 
applied  to  frequent,  watery,  or  mucous  discharges  from 
the  bowels,  attended  with  very  little  or  moderate  griping 


DIARRHCE A AND  DYSENTERY. 


327 


pains,  and  with  but  little  or  no  febrile  excitement — dy- 
sentery, flux , or  bloody  flux , when  the  evacuations  are 
bloody,  or  principally  consist  of  blood  and  mucous  ; there 
are  also  more  or  severer  griping  pains  in  the  bowels,  and 
tenesmus,  with  more  or  less  febrile  excitement.  When 
these  symptoms  are  attended  with  evacuations  which  do 
not  contain  blood,  it  has  been  termed  simple  dysentery 
( Dysenteric/,  alba).  According  to  the  nature  of  the  evacu- 
ations, some  medical  writers  have  made  several  varieties 
of  diarrhoea , as  the  serous , mucous , bilious , &c.  Diarrhoea 
and  dysentery  may  be  acute  or  chronic. 

Diarrhoea  is  caused  by  improper  or  too  much  ingesta, 
and  more  particularly  that  to  which  the  individual  is  not 
accustomed  ; as  fresh  pork,  or  any  other  fresh  or  tainted 
meats,  crude  vegetables,  etc.  It  may  also  be  referred  to 
heat  and  moisture,  to  exposure,  standing  or  lying  for  some 
time  on  wet  or  cold  ground.  Diarrhoea  is  a very  common 
disease  in  the  southern  States,  and  frequently  appears 
in  the  form  of  an  epidemic,  more  particularly  in  the 
spring  and  fall,  sometimes  extending  over  a very  large 
region  of  country,  as  has  been  the  case  the  present 
spring  (1849).  It  also  seems  to  be  a forerunner  of 
Asiatic  cholera,  frequently  appearing  in  a place  or  re- 
gion of  country  a short  time  previous  to,  and  during  the 
prevalence  of,  the  latter  affection,  constituting  what  may 
be  termed  cholerine.  It  not  unfrequently  manifests  itself 
as  an  endemic  in  which  case,  some  of  the  causes  con- 
cerned in  the  production  of  intermittents  probably  play 
an  important  part,  “ The  repercussion  of  acute  and 
chronic  cutaneous  eruptions  sometimes  gives  rise  to  ob- 
stinate attacks  of  the  disease.  It  may  also  be  produced 
by  violent  affections  of  the  mind,  particularly  sudden 
terror  and  grief.  Diarrhoea  occurs  very  frequently  in 
visceral  and  other  local  affections,  attended  with  sup- 
puration and  ulcerative  disorganization.  Thus,  in  the 


328 


BIARRHCEA  AND  DYSENTERY. 


latter  period  of  pulmonary  consumption,  colliquative 
diarrhoea  almost  invariably  occurs ; and  the  same  may 
indeed  be  said  of  every  variety  of  disease  attended 
with  hectic  fever  or  extensive  suppurations.’' — ( Eberle .) 
An  obstinate  form  of  diarrhoea  attends  tabes  mesen- 
t erica,  a disease  of  children,  which  we  have  here- 
tofore noticed.  It  is  also  produced  in  children  by  the 
use  of  bad  milk  (which  is  the  result  of  the  want  of  per- 
fect health  on  the  part  of  the  mother),  or  dentition,  as 
well  as  other  common  causes.  Diarrhoea  attends  or  oc- 
curs in  the  course  of  other  diseases,  and  more  particu- 
larly in  some,  when  irritating  cathartics  have  been  too 
freely  given.  It  is  also  well  known  to  be  a very  common 
disease  amongst  soldiers,  as  was  the  case  with  our  troops 
in  the  recent  campaign  against  Mexico.  Were  these 
cases  caused  entirely  by  exposure,  climate,  bad  diet,  or 
that  to  which  they  were  not  accustomed  ? or  did  animal- 
culae,  taken  into  the  stomach  with  impure  water,  or  tainted 
meat,  or  musty  bread,  have  anything  to  do  in  the  pro- 
duction of  this  almost  universal  disease  amongst  the  vol- 
unteers ? This  hypothesis  appears  somewhat  plausible, 
from  the  fact  that  animalculse  were  very  troublesome  to 
the  wounded,  as  we  have  been  informed.  “ Rolander,  a 
student  in  entomology,  while  he  resided  in  the  house  of 
the- illustrious  Swede,  Linne,  was  attacked  by  diarrhoea 
or  dysentery,  which  quickly  gave  way  to  the  usual  reme- 
dies. Eight  days  after,  it  returned  again,  and  was,  as 
before,  soon- removed.  A third  time,  at  the  end  of  the 
same  period,  he  was  again  seized  with  it.  All  the  while 
he  had  been  living  like  the  rest  of  the  family,  who  had, 
nevertheless,  escaped.  This,  of  course,  occasioned  no 
little  inquiry  into  the  cause  of  what  had  happened. 
Linne,  aware  that  Bartholorioys  had  attributed  the  dys- 
entery to  insects  which  he  professed  to  have  seen,  recom- 
mended it  to  his  pupil  to  examine  his  faeces.  Rolander, 


DIARRHEA  AND  DYSENTERY. 


329 


following  this  advice,  discovered  in  them  innumerable 
animalcules,  which,  upon  a close  examination,  proved  to 
be  mites.  It  -was  next  a question,  how  he  alone  came  to 
be  singled  out  by  them  ; and  thus  he  accounts  for  it : It 
was  his  habit  not  to  drink  at  his  meals ; but  in  the  night, 
growing  thirsty,  he  often  sipped  some  liquid  out  of  a 
vessel  made  of  juniper  wood;  inspecting  this  very  nar- 
rowly, he  observed  in  the  chinks  between  the  ribs  a white 
line,  which,  when  viewed  under  a lens,  he  found  to  con- 
sist of  innumerable  mites,  precisely  the  same  with  those  he 
had  voided.  Various  experiments  were  tried  with  them, 
and  a preparation  of  rhubarb  was  found  to  destroy  them 
most  effectually.  He  afterwards  discovered  them  in  vessels 
containing  acids,  and  often  under  the  bungs  of  casks.”* 

Dr.  Shanks,  of  Memphis,  says  : “ Bowel  affections 
may  truly  be  regarded  as  the  scourge  of  the  Mississippi 
valley.  In  that  portion  bordering  the  Mississippi  river, 
from  St.  Louis  down,  no  season  of  the  year  is  exempt 
from  these  affections,  in  some  one  or  more  of  their  va- 
rious forms. 

“ Diarrhoea,  in  its  various  grades  of  violence,  and  stages 
of  continuance,  is  the  form  most  frequently  presented ; 
and,  indeed,  may  be  said  to  exist,  in  a greater  or  less  de- 
gree, in  all  seasons  of  the  year,  as  the  endemic  of  the 
valley.” 

According  to  Dr.  Searle,  diarrhoea  is  the  mildest  and 
most  prevalent  form  of  disease  resulting  from  the  united 
influence  of  heat  and  malaria,  followed  by  the  conspiring 
one  of  cold,  or  other  concomitant  causes.  “ Dr.  Baly  re- 
fers its  production  invariably  to  a malaria  arising  from 
the  soil,  and  presents  very  plausible  arguments  to  prove 
that  such  was  its  cause  in  the  case  of  the  Millbank  epi- 

* Kerby  and  Spence’s  Entomology.  See  also  South-western  Meet.  Adv., 
Nov.  1847. 

22 


330 


DIARRHCE  A AND  DYSENTERY. 


demic  ; and,  in  the  extension  of  these  arguments  to  prove 
its  constant  production  in  all  situations  by  a telluric  ga- 
seous poison,  he  adduces  the  close  alliance  between  dys- 
entery and  other  diseases  which  are  more  indisputably 
of  miasmatic  origin,  namely,  common  cholera  and  fever , 
and  the  fact  that  not  merely  have  epidemics  of  dysentery 
in  the  penitentiary  been  produced  or  followed  by  the 
prevalence  of  one  or  other  of  these  diseases,  but  that  an 
attack  of  dysentery  has  often  been  ushered  in  by  cholera, 
or  has  been  combined  with  fever,  particularly  typhus 
and  typhoid,  in  the  same  patient.”* 

Dysentery  is  most  prevalent  in  hot  or  warm  climates, 
and  in  the  summer  and  fall  seasons  of  the  year.  It  also 
occurs  in  camps  amongst  soldiers,  especially  those  sta- 
tioned in  warm  countries;  and,  occasionally,  in  prisons; 
and  not  unfrequently  as  an  epidemic,  or  endemic,  or 
sporadically,  in  the  southern  and  south-western  States. 
Rains,  following  a long  dry  spell,  especially  if  accom- 
panied with  cool  weather,  in  the  spring,  summer,  or 
autumn,  often  produce  dysentery. 

Dr.  Casselberry,  of  Evansville,  Indiana,  describes  an 
epidemic  dysentery  which  prevailed  in  that  city  and  vi- 
cinity, after  the  first  of  June,  1848,  and  which  he  refers 
to  malaria.  The  unusually  wet  season,  warm  days,  and 
cool  nights,  apply  to  dysentery  generally ; as  do  also  the 
earlier  symptoms  wfiiich  he  gives;  although,  in  many 
instances,  dysentery  appears  with  but  slight  and  short 
premonitory  symptoms. 

Dr.  Casselberry  observes : “ The  dysenteric  affection 
is  usually  preceded  for  a day  or  two  by  premonitory 
symptoms,  more  or  less  marked ; such  as  languor,  lassi- 
tude, debility,  and  a sensation  of  weight  or  oppression  in 
the  epigastric  region,  with  shooting  pains  through  the 


* By  D.  F.  C.  Amer.  Journ,  Med.  Sci.,  Jan.  1848,  p.  216. 


DIARRHOEA  AND  DYSENTERY. 


331 


bowels.  The  tongue  is  coated  with  a brownish  fur  along 
the  middle,  with  red  edges  and  tip.”  To  continue  a de- 
scription of  an  attack  of  dysentery ; the  first  manifesta- 
tions of  the  disease  maybe  as  follows:  Want  of  appe- 
tite ; a bad  taste  in  the  mouth,  frequently  succeeded  by 
nausea;  and  this  soon  by  chilly  sensations,  commonly 
with  occasional  flushes  of  heat ; pulse  small,  and  more 
or  less  contracted ; extremities  cool,  and  the  general  sur- 
face less  so,  sometimes  followed  or  alternated  with  warm, 
dry  skin,  and  perhaps  thirst.  After  a longer  or  shorter 
period,  from  a few  hours  to  a day  or  two,  the  febrile 
symptoms  become  more  permanently  developed,  and  the 
pains  in  the  bowels  more  griping,  with  less  or  more 
alvine  discharges,  wThich  may  have  been  preceded  by 
some  degree  of  costiveness.  The  first  evacuations  are 
commonly  diarrhceal,  the  griping  pains  and  tenesmus 
become  more  and  more  intense,  and  after  a time  the 
bloody  stools,  or  mucus  mixed  with  blood,  appear. — 
The  disease  may  make  its  appearance  almost  suddenly, 
wdthout  any  premonitory  symptoms,  except  perhaps  for 
a short  time ; and  this  is  more  likely  to  occur  when  it 
has  been  produced  by  improper  ingesta.  “ Tenesmus 
is  one  of  the  most  constant  and  characteristic  attend- 
ants on  this  affection ; and  the  violence  of  this  painful 
symptom  affords  us  a pretty  accurate  measure  of  the 
violence  and  degree  of  danger  of  the  disease.  There 
is  often  considerable  pain  and  difficulty  experienced 
in  voiding  urine.  The  tormina  are  extremely  distress- 
ing, particularly  just  before  the  urgent  calls  to  stool 
are  experienced  ; and  a constant  soreness  is  felt  in  the 
abdomen.  The  dysenteric  discharges  usually  have  a 
very  peculiar,  disagreeable  smell,  but  no  fetor  in  the 
beginning  of  the  disease;  but  in  the  advanced  period 
of  violent  and  dangerous  cases,  they  frequently  possess 
a pungent  and  cadaverous  smell,  and  acquire  a corroding 


332 


DIARRHCEA  AND  DYSENTERY. 


and  sanious  character.  Sometimes  a colliquative  diar- 
rhoea occurs  a few  days  previous  to  the  fatal  termina- 
tion of  the  disease.  In  some  instances,  the  heart  and 
arteries  sympathize  but  very  little  with  the  local  mucous 
inflammation,  the  febrile  phenomena  being  scarcely  per- 
ceptible ; but  much  more  commonly  the  attending  fever 
is  of  a high  grade.  In  protracted  and  unsubdued  cases, 
great  prostration  ensues;  the  pulse  becomes  small,  cord- 
ed, and  very  frequent;  the  countenance  contracted  and 
cadaverous;  the  abdomen  tender  and  inelastic,  and  some- 
times flat;  the  skin  harsh  and  shrunk;  the  breath  offen- 
sive, and  the  gums  tender  and  swollen.  An  apparent 
amendment  occasionally  occurs  after  these  dangerous 
symptoms  have  come  on,  but  this  truce  generally  lasts 
but  for  a short  time ; for,  although  the  pulse  rises  and 
becomes  better,  and  the  tenesmus  and  tormina  remit,  the 
restlessness  and  anxiety  increase ; the  stools  become 
liquid,  dark,  pungent,  offensive  ; the  countenance  hippo- 
cratic ; the  extremities  cold,  and  the  surface  of  the  body 
moist  and  clammy.  At  first,  the  tongue  is  covered  with 
a white  fur,  becoming  brown,  rough,  and  dry  along  the 
middle  in  the  progress  of  the  disease,  with  red  and  moist 
edges.  In  cases  of  a protracted  or  subacute  character, 
the  edges  and  tip  of  the  tongue  usually  become  clean, 
smooth,  and  florid  ; and  in  the  chronic  form  of  the  dis- 
ease, the  whole  surface  is  often  smooth,  clean,  and  red,  or 
red  and  granulated,  like  raw  flesh.  The  urine  is  always 
scanty  and  high  colored,  and  sometimes  of  a pungent 
odor.” — ( Eberle .)  In  some  instances,  there  is  great  gastric 
irritability,  in  which  case  it  is  almost  impossible  to  get 
the  stomach  to  retain  any  medicine.  The  premonitory 
symptoms  are  frequently  analogous  to  those  of  intermit- 
tent or  remittent  fever. 

When  diarrhoea  and  dysentery  become  chronic,  the 
system  usually  becomes  very  much  prostrated — debili- 


DIARRHOEA  AND  DYSENTERY— PATHOLOGY. 


333 


tated,  the  features  pallid,  the  eyes  sunk  in  the  sockets; 
the  individual  gets  very  poor,  the  flesh  being  very  much 
reduced,  soft,  and  flabby;  the  appetite  fastidious;  the 
bowels  easily  affected  by  improper,  or  too  much  diet; 
occasionally,  there  are  hectic  flushes  on  the  cheeks,  with 
some  degree  of  fever.  Many  such  cases,  wdien  treated 
principally  with  mercurials — which  is  too  common, 
even  at  the  present  day,  under  the  delusion  that  the  de- 
rangement of  the  liver  is  the  principal  cause  of  the  dis- 
ease— become  worse  and  worse,  swelling  of  the  feet  and 
ankles  takes  place,  and  in  some  cases  dropsical  effusions 
elsewhere,  till,  finally,  death  closes  the  scene.  In  other 
cases,  the  discharge  from  the  bowels  becomes  less  and 
less,  is  more  of  a mucous  character,  or  is  composed  al- 
most entirely  of  mucus  and  a little  fseces,  and  the  indi- 
vidual slowly  recovers. 

These  diseases  may,  sometimes,  depend  on  hardened 
fseces  accumulating  and  producing  irritation  and  inflam- 
mation in  the  bowels;  but  this  cause  is  rare;  far  more  so 
than  was  supposed  by  the  older  writers. 

Pathology. — In  all  cases  of  diarrhoea  and  dysentery, 
with  the  exception  of  those  caused  by  irritating  matters 
in  the  alimentary  canal,  it  would  appear  that  the  chief 
primary  morbid  impression  is  made  on  the  nervous  sys- 
tem. But,  be  the  cause  whatever  it  may,  the  local  pa- 
thological condition  consists  in  irritation  or  inflammation , 
or  both ; and  in  protracted  or  chronic  cases,  ulceration 
of  the  mucous  membrane  of  the  colon;  and  in  many 
instances  also  the  caecum,  lower  portion  of  the  ileum,  and 
rectum;  and,  in  some  cases,  affecting  the  mucous  mem- 
brane throughout  the  whole  extent  of  the  alimentary 
tract.  If  the  disease  lasts  for  some  time,  the  other  coats 
of  the  bowel  may  become  affected,  and  the  bowel  may 
even  be  entirely  perforated.  William  Baly,  M.  D.,  phy- 


334 


DIARRHOEA.  AND  DYSENTERY— PATHOLOGY. 


sician  to  the  Millbank  prison,  and  lecturer  on  Forensic 
Medicine  at  St.  Bartholomew’s  hospital,  speaking  of 
dysentery,  says:  “When  the  inflammatory  action  has 
continued  long  in  a subacute  form,  the  submucous  coat 
is  found  much  thickened,  and,  at  an  advanced  period  of 
the  disease,  much  indurated  in  the  situation  of  the  ulcers. 
The  contraction  of  these  thickened  parts,  in  the  manner 
of  the  cicatrices  of  burns,  sometimes  is  productive  of 
strictures  of  the  intestine. 

“ Dysentery,  in  its  most  severe  degree,  is  frequently 
fatal  in  a few  days.  The  inflammation  affecting  a large 
extent  of  the  mucous  membrane,  reduces  it  with  extreme 
rapidity  to  the  state  of  sphacelus.  In  the  parts  most  in- 
tensely inflamed,  the  whole  mucous  membrane  is  found 
swollen,  and  of  a dark  purple  color,  or  its  texture  is  dis- 
organized, and  its  color  black,  green,  or  brown. 

“ When  inflammation  of  this  degree  of  intensity  affects 
a large  extent  of  the  intestine,  death  generally  ensues 
very  rapidly.  This  is  not,  however,  always  the  case; 
and  when  life  is  prolonged  for  several  weeks,  we  see  far- 
ther stages  of  the  disease,  or,  perhaps,  I should  rather 
say,  changes  in  the  parts  which  the  disease  has  destroyed, 
namely,  the  softening  and  the  separation  of  the  sloughs. 

“ It  seems  scarcely  possible  that  life  should  long  be 
maintained  with  a large  portion  of  the  alimentary  canal 
in  such  a condition  as  this;  but  v’here  the  gangrenous 
process  has  not  affected  the  coats  so  deeply,  the  patients 
survive  for  some  time  the  loss,  by  sloughing,  of  the  mu- 
cous membrane,  and  of  much  of  the  submucous  tissue 
through  more  than  half  the  length  of  the  large  intes- 

O O O 

tines. 

“ When  the  lower  part  of  the  intestine  is  the  seat  of 
the  disease,  in  cases  of  dysentery,  a tolerably  accurate 
estimate  of  the  extent  of  mucous  membrane  affected 
may  be  formed,  from  the  mere  quantity  of  bloody  mucus 


DIARRHCEA  AND  DYSENTERY— PATHOLOGY. 


335 


discharged.  The  source  of  this  bloody  and  mucous  dis- 
charge in  the  acute  stage  of  dysentery  is  not  the  solitary 
glands,  but  the  tubular  follicles  of  the  mucous  membrane. 
In  the  chronic  stage  of  dysentery,  also,  pus,  or  a puriform 
matter,  is  often  excreted.”  This  matter  “ probably  comes, 
in  the  slighter  cases,  from  the  enlarged  and  diseased  soli- 
tary glands,  and  in  the  more  severe  cases  from  the  nu- 
merous ulcers  which  have  been  left  after  the  destruction 
of  the  glands,  and  of  smaller  or  larger  portions  of  the 
mucous  membrane.”* 

Dr.  Bell,  of  Philadelphia,  says:  “Viewed  anatomi- 
cally, there  is  no  essential  difference”  in  diarrhoea  and 
dysentery.  When  diarrhoea  is  of  long  standing,  it  is 
said,  in  some  cases,  to  be  kept  up  by  an  ulcer  in  the  rec- 
tum, near  the  verge  of  the  anus.  This  is  said  to  “ occur 
chiefly  in  persons  of  broken  down  constitutions,  and 
those  who  have  taken  a great  deal  of  mercury.” 

W.  S.  W.  Ruschenberger,  M.  D.,  Surgeon  U.  S.  Navy, 
Fleet  Surgeon  for  the  U.  S.  Squadron  on  the  East  India 
Station,  reports  the  two  following  fatal  cases,  taken  from 
the  records  of  the  U.  S.  Naval  Hospital,  New  York, 
from  notes  by  Assistant  Surgeon,  Joseph  Hopkinson. 

“ On  the  1st  of  April,  1847,  the  U.  S.  ship  Vincennes, 
after  a cruise  in  the  East  Indian  and  China  seas,  arrived 
in  the  port  of  New  York.  The  crew  had  suffered  se- 
verely from  tropical  dysentery,  and  those  men  who  were 
attending  to  duty  w’ere  considerably  enfeebled,  either  by 
disease  or  extra  labor,  imposed  on  them  in  consequence 
of  the  number  sick  and  therefore  unable  to  work.  Of 
a crew  of  about  one  hundred  and  eighty,  thirty-five  were 
admitted  into  hospital,  suffering  from  chronic  disease; 
of  this  number,  twenty-two  were  affected  with  dysentery. 
Of  the  latter,  nineteen  were  cured,  one  was  discharged 
very  much  improved,  and  two  died.” 


* See  Amer.  Journ.  of  Med.  Sci.,  Jan.  1848. 


336 


DIARRHCEA  AND  DYSENTERY— PATHOLOGY. 


“ Case  I.  Dysentery  complicated  with  Pneumonia. — 
Daniel  Green,  gunner’s  mate,  aged  fifty-five,  received 
from  the  U.  S.  ship  Vincennes,  April  2d,  was  admitted 
for  treatment  on  board,  January  7th,  1847;  had  been 
complaining  two  months  previously ; while  on  board,  he 
was  treated  with  mercurials,  opiates,  and  topical  deple- 
tion. Now  emaciated ; sallow,  dry,  harsh,  shrivelled  skin ; 
tongue  dry,  smooth,  striped  longitudinally,  florid ; pulse 
regular,  small,  feeble,  seventy-six.  Milk  diet.”  He  was 
treated  till  11th  of  April,  when  he  expired. 

“ Autopsy,  nine  hours  after  death. — Body  very  much 
emaciated ; oedema  of  the  feet  and  legs ; abdomen  ine- 
lastic and  sunken.  Abdomen. — Omentum  free  from  fat; 
peritoneum  thickened,  and  readily  separable  from  its  at- 
tachments. Liver — was  of  normal  size,  but  its  substance 
soft  and  friable ; the  upper  surface  was  marked  by  nu- 
merous white,  stellate  spots,  and,  near  the  left  extremity, 
covered  with  white,  thickened,  granular  membrane.  The 
gall-bladder,  which  adhered  closely  to  the  colon,  con- 
tained four  ounces  of  thin,  lemon-colored  bile.  The 
spleen  was  small  and  hard.  The  stomach  was  normal  in 
size  and  external  appearance ; the  mucous  coat  firm. 
Near  the  pylorus,  the  coats  were  generally  thickened, 
and  close  to  the  pyloric  orifice,  which  was  considerably 
contracted,  wTas  a heart-shaped  ulcer,  about  a quarter  of 
an  inch  in  diameter.  The  coats  of  the  duodenum  were 
thickened,  and  the  internal  diameter  of  the  intestine  con- 
siderably diminished,  but  the  glands  of  Brunner  were 
not  discernible.  The  small  intestines  were  not  remark- 
able; but  the  mesenteric  vessels  were  injected,  turgid. 
The  colon  was  contracted  in  its  diameter;  its  parietes 
very  much  thickened,  the  mucous  coat  of  a dark  slate 
color,  and  its  whole  surface  thickly  set  with  large  ulcers. 
The  mucous  coat  of  the  rectum  was  injected,  but  not  ulce- 


DIARRHCEA  AND  DYSENTERY— PATHOLOGY. 


337 


rated.  The  bladder  was  distended;  its  coats  were  thick- 
ened. 

“ Thorax . — Lungs  did  not  collapse  ; extensive,  but  not 
very  firm  pleuritic  adhesions  on  both  sides ; pleura  adhe- 
rent to  pericardium.  In  the  apex,  and  also  in  the  upper 
portion  of  the  middle  of  the  left  lung,  there  were  cavities, 
each  containing  about  an  ounce  of  dark,  olive-colored, 
offensive  matter.  The  parietes  of  these  cavities  were 
covered  by  an  exudation  of  lymph.  Lung  distended, 
and  filled  with  frothy  serum,  and  studded  with  small, 
blackish  tubercles.  The  right  lung  more  crepitant 
than  the  left ; the  upper  lobe  studded  throughout 
with  tubercles,  and  distended  with  serum;  texture  of 
both  lungs  softer  than  usual.  The  substance  of  the  heart 
was  preternaturaily  soft,  and  otherwise  diseased.  The 
pericardial  sac  contained  about  tvTo  ounces  of  serum,  of 
the  color  of  olive  oil,  and  was  found  to  be  highly  alkaline. 

“ Case  II. — Autopsy. — Body  rigid,  emaciated.  Lungs 
and  heart  healthy.  Abdomen. — Omentum  very  much 
injected,  and  adherent  to  the  left  iliac  fossa,  and  to  the 
colon  throughout  its  whole  course.  Liver  pale  and  soft- 
ened ; gall  bladder  nearly  empty.  Spleen  adherent  to 
left  kidney.  Stomach  normal  in  appearance  and  size ; 
mucous  coat  firm  ; near  pyloric  end  was  a pediculated, 
dark-colored  tumor,  of  cartilaginous  consistence,  mea- 
suring a quarter  of  an  inch  long  by  one-eighth  of  an  inch 
in  diameter.  Pyloric  orifice  and  duodenum  thickened  ; 
glands  of  Brunner  well  marked  and  healthy ; small  in- 
testines distended  to  twice  their  normal  diameter.  Colon , 
covered  by  the  thickened  omentum  throughout  its  extent, 
seemed  as  if  rolled  up  in  it;  on  cutting  through  this  en- 
velop, the  great  intestine  was  found  to  be  a mass  of 
softened,  dark,  slate-colored  tissue  and  pus,  at  several 
points  completely  perforated  by  ulceration ; the  gut  readily 
tore  transversely  almost  by  its  own  weight.  Yellow, 


338 


DIARRHEA  AND  DYSENTERY— PATHOLOGY. 


fecal  matter  was  found  smeared  over  the  inferior  part  of 
the  cavity  of  the  peritoneum ; the  sigmoid  flexure  was 
bound  down  in  the  iliac  fossa  by  thickened  omentum,  as 
if  an  effort  had  been  made  to  prevent  extravasation  at 
that  point.”* 

I will  briefly  notice  the  appearances  on  post-mortem 
examinations  in  some  fatal  cases  that  occurred  in 
the  Cincinnati  Commercial  Hospital,  reported  by  Pro- 
fessor J.  P.  Harrison,  M.  D.  James  Early,  boatman, 
aged  37  years.  Examination  15  hours  after  death.  Ab- 
domen.— Externally,  the  intestines  presented  a leaden 
hue;  the  entire  tract  of  the  colon,  on  the  internal  coat, 
was  of  a dark  appearance ; the  lower  half  of  the  ileum 
was  of  a deep  red  color,  with  some  small,  ulcerated  spots 
visible  along  the  lower  portion.  The  other  viscera 
healthy.  (2.)  Samuel  Butcher,  aged  25  years.  Exam- 
ined eight  hours  after  death.  Abdomen. — Colon  hyper- 
trophied throughout  its  whole  extent;  all  the  coats 
thickened,  but  in  an  especial  manner  the  mucous;  nu- 
merous ulcers,  penetrating  deep  into  the  hypertrophied 
mucous  coat,  studded  the  whole  length  of  the  colon; 
the  lower  portion  (one-third)  of  the  ileum  was  likewise 
hypertrophied  and  ulcerated.  The  stomach,  duodenum, 
and  jejunum  healthy.  (3.)  Joseph  Campbell,  aged  35 
years,  admitted  November  25th,  1845.  Sectio  cadaueris. 
Abdomen. — The  stomach  and  small  intestines  were  alto- 
gether natural  in  appearance.  Colon , along  its  entire 
tract,  from  the  caput  caecum  coli  to  the  rectum,  was 
studded  with  ulcers,  generally  of  the  size  of  a split  pea, 
but  several  of  them  much  larger.  These  larger  ulcers 
had  penetrated  through  the  mucous  and  muscular  coats 
down  to  the  peritoneal  investment  of  the  bowels.  The 
liver  and  spleen , also  the  rectum,  were  healthy  in  aspect 


* See  Amer.  Journ.  Med.  Sci.,  Oct.  1848. 


DIARRHOEA  AND  DYSENTERY— PATHOLOGY. 


339 


and  size.  (4.)  Richard  Bradshaw,  aged  33  years,  was 
admitted  June  22d,  1846.  Sectio  cadaveris.  Abdomen. — 
Ileum  was  of  a deep  red  aspect  in  the  lower  part  of  its 
mucous  coat ; colon  thickened  in  its  whole  extent — its 
calibre  much  contracted,  especially  in  the  descending  por- 
tion ; completely  studded  with  small  ulcers  in  its  whole 
extent  of  internal  membrane ; mesenteric  glands  were 
enlarged ; the  urinary  bladder  was  thickened,  and  the 
mucous  coat  of  a deep  red  hue  ; the  rectum  was  likewise, 
in  its  mucous  coat,  of  an  intensely  red  appearance.  The 
other  organs  of  the  body  healthy  in  size  and  appearance. 
(5.)  William  Crawley,  aged  24  years,  admitted  June  3d, 
1846.  Has  had  bad  health  fora  year,  during  which  time 
he  has  suffered  from  repeated  attacks  of  intermittent 
fever.  Died  of  diarrhoea,  24th  June.  The  spleen  was 
found  enlarged;  liver  healthy;  the  mesenteric  glands 
augmented  in  size,  and  indurated ; the  mucous  coat  of 
the  small  intestines  was  of  a deep  red  color ; ulcerated 
spots  were  found  in  the  ileum,  and  to  a greater  degree  in 
the  colon.  The  mucous  membrane  of  the  urinary  blad- 
der of  a deep  red  color. — ( Western  Lancet,  Nov.  and 
Dec.,  1847.) 

Perhaps  I have  been  unnecessarily  tedious  or  particu- 
lar in  giving  the  local  pathological  conditions  in  diarrhoea 
and  dysentery,  but  my  object  is  to  impress  its  pa- 
thology on  the  mind  of  the  reader,  and  to  show  the  delu- 
sion or  mistaken  notions  of  those  who  refer  these  diseases 
to  the  liver,  and  consequently  resort  to  the  too  liberal 
and  injudicious  use  of  calomel  and  blue  mass.  In  some 
of  the  above  protracted  cases,  it  will  be  seen  that  some 
of  the  organs  were  softer  than  natural ; but  this  may  be 
referred  to  the  changed  and  impoverished  condition  of  the 
blood,  and  the  continued  low  vitality  of  the  general  sys- 
tem, as  is  the  case  in  protracted  fevers.  According  to 
Prof.  Harrison,  “During  the  whole  of  1846,  fifty-six  cases 


340 


DIARRHCEA  AND  DYSENTERY— TREATMENT. 


of  diarrhoea  were  brought  into  the  hospital,  and  of  these 
twenty-five  died.”  The  doctor  says  that  some  of  these 
were  received  when  almost  in  articulo  mortis.  It  would 
seem  from  his  language  that  very  few  were  brought  in 
in  this  condition.  It  appears  that  he  relied  mostly  on 
mercurials,  adding  other  adjuvantia.  Balsam  eopaiva 
was  used  in  some  cases;  but  Prof.  Harrison  says,  it  “did 
not,  in  our  hands,  answer  the  expectation  which  we  once 
entertained  of  its  efficacy.”  If  other  testimony  were 
wanting,  which  is  far  from  being  the  case,  this  great  mor- 
tality is  sufficient  to  prove  the  impropriety  of  the  mer- 
curial practice  in  these  affections.  I could  refer  to  the 
experience  of  many  physicians,  to  show’  that  mercurials 
not  only  often  do  no  good,  but  do  actual  harm — are  often 
detrimental,  indeed  fatal. 

Treatment. — By  reference  to  the  pathology  and  post- 
mortem examinations  above,  we  may  be  able  to,  form  a 
pretty  correct  idea  of  the  proper  treatment  demanded  ; 
and  also  readily  infer  how  injudicious  and  injurious  must 
be  the  mercurial  and  cathartic  practice,  heretofore,  and  at 
present,  too  much  adopted  in  the  management  of  diar- 
rhoea and  dysentery.  In  order  to  adopt  a rational  mode 
of  treatment,  let  us  keep  in  view  the  morbid  condition  of 
the  bowrels,  their  mobility  or  peristaltic  movements,  their 
functions,  and  the  condition  of  the  general  system.  In- 
stead of  increasing  the  movements  of  the  bowels,  they 
should  be  kept  quieted,  in  order  that  they  may  have  an 
opportunity  to  heal. 

If  diarrhoea  is  produced  by  improper  ingesta,  we  should 
look  upon  this  effort  of  the  bow’els  to  get  rid  of  that  which 
affects  them  unpleasantly  or  disagreeably  in  the  same 
light  that  wre  would  cathartics,  which  produce  the  same 
or  a similar  effect ; and  who  would  think  of  curing  a 
disease  by  increasing  it  ? The  plain  indication  then,  is, 


DIARRHCEA  AND  DYSENTERY— TREATMENT. 


341 


if  the  system  has  not  already  got  rid  of  the  offending 
matter,  which,  however,  it  usually  soon  does,  to  wait  a 
short  time,  if  the  patient  is  in  no  pain,  till  the  cause  of 
the  irritation  is  removed,  or  gently  aid  the  system  to  re- 
move it ; as  by  a small  dose  of  rhubarb  or  castor  oil,  or 
other  aperients;  to  which  should  be  added,  if  there  is 
pain  or  griping,  a little  paregoric  or  laudanum ; after 
which  the  irritation  should  be  controlled  by  opiates  ; as 
a teaspoonful  or  two  of  paregoric,  or  from  twenty  to  thirty 
drops  of  laudanum.  This  will  usually  put  a stop  to  the 
disease  almost  immediately ; but,  if  it  should  not,  the 
opiates  should  he  repeated  two  or  three  times  a day,  or  as 
often  as  the  condition  of  the  patient  requires.  If  the 
diarrhoea  comes  on  spontaneously,  not  being  referable  to 
errors  in  eating;  as,  for  instance,  when  it  is  produced  by 
the  relaxing  influence  of  heat  and  moisture,  exposure  to 
cold  or  cool  damp  weather;  when  it  occurs  as  an  epidemic, 
or  is  produced  by  water,  in  travellers,  to  which  they  are 
not  accustomed,  the  opiate  should  be  given  at  once,  with- 
out any  delay  ; and,  even  in  cases  that  are  produced  by 
irritants  in  the  bowels,  an  opiate  will  generally  control, 
or  at  least  greatly  modify  the  irritation,  even  while  the 
irritating  matter  is  in  the  alimentary  canal,  and  allow  the 
bowels  to  gently  expel  it;  ora  little  rhubarb  or  castor  oil 
and  paregoric  or  laudanum  may  be  given  together,  if  ne- 
cessary, both  to  allay  the  irritation  and  assist  the  bowels 
to  remove  the  irritating  matter. 

In  cases  of  diarrhoea  that  have  lasted  for  several  days, 
a week,  or  more,  it  will  be  advisable  to  combine  astrin- 
gents with  the  opiates,  which  may  commonly  be  done 
at  the  commencement  of  the  treatment,  in  this  country; 
and,  in  cases  of  a chronic  character,  astringent  tonics 
should  also  be  combined  with  them.  If  the  case  is  of 
recent  standing,  a mixture  of  equal  parts  of  paregoric  and 
tincture  of  cinnamon — dose,  twro  or  three  teaspoonfuls, 


342 


DIARRHOEA  AND  DYSENTERY— TREATMEN  T. 


two,  three,  or  four  times  a day,  as  occasion  requires — will 
usually  soon  succeed  in  arresting  it.  Tincture  of  rhatany 
(krameria),  catechu,  kino,  or  nutgalls,  may  be  mixed  with 
the  paregoric,  and  taken  in  the  same  doses  as  the  above. 
If  the  disease  is  obstinate  or  severe,  any  of  these  tinc- 
tures may  be  mixed  with  laudanum,  in  the  proportion 
of  one  ounce  of  the  latter  to  two  ounces  of  the  former  ; 
dose,  from  one  to  two  teaspoonfuls,  twice  a day,  or  as 
often  as  is  necessary ; or  three  or  four  grains  of  sugar  of 
lead  may  be  given  with  a grain  or  two  of  opium,  or  thirty 
or  forty  drops  of  laudanum,  to  be  repeated  as  above.  The 
following  may  be  given  in  these  severe  cases : catechu 
and  kino,  in  powder,  ten  grains  of  each,  to  which  should 
be  added  a teaspoonful  or  two  of  paregoric,  or  thirty  or 
forty  drops  of  laudanum,  or  from  one-quarter  to  one-half 
a grain  of  sulphate  of  morphine.  In  all  cases  of  any  se- 
verity, and  even  milder  ones,  opium,  or  some  of  its  pre- 
parations, should  be  regarded  as  the  most  important 
article,  and  therefore  should  constitute  the  principal  reme- 
dy, and  be  given  in  sufficiently  large  doses  to  control  or 
modify  the  irritation  and  too  great  peristaltic  action  of  the 
bowels,  and  the  frequent  discharges  from  them.  Tannin 
is  a powerful  astringent,  and  may  be  given  in  two-grain 
doses,  like  the  above  astringents,  wfith  opiates,  when  their 
use  is  demanded.  Oak  bark,  persimmon — the  green  fruit 
or  bark,  logwood,  blackberry  or  dewberry  root,  alum,  and 
other  astringents,  may  also  be  used,  when  none  of  the 
above-mentioned  ones  are  at  hand  ; a little  paregoric  or 
laudanum  should  be  given  with  a decoction  or  infusion 
of  either  of  these.  In  children,  the  dose  of  any  of  the 
above  should  be  reduced  in  proportion  to  the  age.  In 
very  young  children,  opium,  morphine,  or  laudanum 
should  not  be  given,  it  being  safer  and  better  to  give  from 
five  to  twelve  or  fifteen  drops  of  paregoric,  with  some  of 
the  astringents. 


DIARRHCEA  AND  DYSENTERY— TREATMENT. 


343 


I have  never  found  any  difficulty  in  promptly  arrest- 
ing acute  cases  of  diarrhoea  and  dysentery  by  the  liberal 
use  of  opiates,  and  in  some  cases  the  addition  of  astrin- 
gents. I find  that  there  is  a too  prevalent  opinion  or 
prejudice,  even  amongst  the  more  intelligent,  against 
stopping  a diarrhoea  or  dysentery  too  soon,  for  fear  it  will 
prove  injurious  by  setting  up  disease,  or  throwing  the 
morbid  action  on  other  organs.  This  was  the  opinion  of 
some  of  the  older  writers,  and  it  appears  to  be  still  main- 
tained by  our  northern  brethren,  as  well  as  by  European 
authors;  and  we  might,  therefore,  presume  that  there  are 
some  grounds  for  these  opinions  amongst  them ; but,  be 
this  as  it  may,  so  far  as  my  own  practice  and  observation 
extend,  this  position  does  not  hold  good  in  the  South.  I 
have  myself  many  times  been  attacked  with  a profluvia 
of  this  sort,  and  stopped  it  almost  immediately  by  a large 
dose  of  paregoric,  without  any  other  than  good  results 
following ; and  though,  in  many  of  these  cases,  the  stools 
will  look  of  a light  color  for  a day  or  two,  no  calomel  is 
necessary.  This  I have  observed  time  and  again,  in  nu- 
merous instances. 

The  stomach  is  not  usually  so  irritable  but  that  it 
will  retain  the  medicines ; but,  in  case  it  should  be,  a tea- 
spoonful of  laudanum,  with  six  or  eight  grains  of  sugar 
of  lead,  should  be  put  in  an  ounce  of  thin  starch  or  flour 
gruel,  or  tepid  water,  and  given  by  injection;  which 
should  be  repeated  two  or  three  times  a day,  or  more  or 
less  frequently,  as  the  condition  of  the  patient  requires ; 
or  a large,  soft  pill  of  opium  may  be  introduced  into  the 
rectum,  and  repeated  in  the  same  manner.  A warm 
cataplasm  or  poultice  laid  over  the  stomach  and  abdo- 
men, may  be  of  much  service  as  an  adjuvant,  in  severe 
cases,  especially  those  attended  with  much  griping  pains 
in  the  bowels.  In  cases  that  are  somewhat  protracted, 
and  in  which  the  system  has  become  relaxed  and  debili- 


344 


DIARRHOEA  AND  DYSENTERY— TREATMENT. 


tated,  I have  reason  to  believe  that  a cool  shower  bath 
once  a day  will  be  of  service. 

Some  speak  favorably  of  the  use  of  kreosote.  Dr. 
May  says  : “The  form  of  diarrhoea  to  wThich  kreosote  ap- 
pears particularly  applicable,  is  that  unaccompanied  by 
much  pain  and  febrile  excitement,  but  which,  after  the 
operation  of  a mild  aperient,  requires  the  use  of  absorbents 
and  astringents  to  check  the  frequent  watery  alvine  de- 
jections. These  cases  are  common  enough,  and  the  phy- 
sician is  seldom  called  in  to  prescribe  for  them  ; never, 
indeed,  unless  the  diarrhoea  resists  for  some  time  all  the 
various  astringents  used  in  domestic  practice.  In  such 
cases,  I can  confidently  recommend  the  kreosote  as  being 
speedy  and  certain  in  its  effects ; restraining  the  dis- 
charges, but  not  producing  constipation.  This  effect  has 
been  produced  in  all  cases  in  which  it  has  been  pre- 
scribed, and  is,  in  my  opinion,  its  chief  recommendation.” 
Two  prescriptions  are  employed  : — 

Emulsion.  R.  Gum  Arabic  one  drachm  ; 

Loaf  sugar  one  drachm  ; 

Kreosote  four  drops  ; 

Water  two  ounces. 

Mix  intimately.  Dose,  tablespoonful  or  more;  for  a 
child,  a teaspoonful,  three  times  a day. 

Pills.  R.  Opium  eight  grains; 

Kreosote  five  drops ; 

Liquorice  sufficient  to  make  eight  pills. 

Dose,  one  pill.  Dr.  May  suggests  that  the  presence 
of  fever  would  forbid  its  employment.  Dr.  Mayes  de- 
tails two  cases  of  diarrhoea,  with  emaciation,  coming  on 
after  weaning,  which  he  successfully  treated  with  the 
kreosote,  etc.  The  first,  a little  girl;  whose  condition 
is  described  as  follows : Pale,  leucophlegmatic  coun- 
tenance; abdomen  tumid  and  very  hot,  complaining 
of  much  pain  under  pressure ; stools  excessively  fetid 


DIARRHOEA  AND  DYSENTERY— TREATMENT. 


345 


and  dark  colored,  also  frequent;  constant  harassing,  dry 
cough ; great  emaciation,  so  much  so  that  the  integument 
on  the  extremities  seemed  sufficient  for  a second  cover- 
ing ; no  appetite  at  all,  and  some  irritability  of  sto- 
mach; cold  drinks  could  be  retained,  but  everything 
else  was  refused.  This  assemblage  of  symptoms  was 
indicative  of  a fatal  termination  of  the  case,  and  that 
speedily,  unless  some  powerful  remedy  could  arrest  the 
progress  of  the  disease.”  A teaspoonful  of  the  kreosote 
emulsion  was  given  three  times  a day : “ at  the  same 
time,  the  tepid  bath,  medicated  by  an  astringent  infu- 
sion, was  used  two  or  three  times  daily ; after  a few 
days,  the  cold  bath  was  used,  medicated  in  the  same 
manner.  In  less  than  three  days,  the  beneficial  effects 
of  this  treatment  were  perceptible  in  the  improved  ap- 
pearance of  the  alvine  discharges.  Her  amendment 
from  this  time  was  rapidly  progressive.  The  last  mix- 
ture made  up  for  her  was  : R.  Kreosote,  six  drops  ; loaf 
sugar,  gum  Arabic,  each  one  drachm ; carbonate  of  iron, 
half  a drachm  ; water,  four  ounces — Mix.  The  vial  to  be 
well  shaken  before  measuring  a dose.  A teaspoonful  was 
directed  three  times  a day.  After  using  this  mixture,  no 
further  medical  treatment  was  thought  necessary,  but  a 
nourishing  diet  and  exercise  were  advised.”* 

In  cases  of  chronic  diarrhoea,  if  the  above  means 
fail  to  effect  a cure,  the  nitrate  of  silver,  with  opiates, 
is  one  of  our  most  valuable  resources.  The  nitrate  is 
recently  becoming  more  generally  used  in  chronic 
diarrhoea  and  dysentery.  It  is  given  in  doses  of  from 
a quarter  to  a grain,  dissolved  in  some  mucilaginous 
solution,  or  made  into  pill  with  powdered  liquorice,  or 
other  vehicle.  The  following  formula  will  answer  for 
the  solution  : — 

* See  Western  Lancet,  Nov.  1846,  pp.  297-8.  Also,  May,  1847. 

23 


346 


diarrhcea  and  dysentery— treatment. 


R.  Nitrate  of  silver  one  scruple; 
Pure  water  eight  ounces  ; 

Gum  Arabic  two  drachms ; 

White  sugar  two  drachms. 


Mix  well,  and  shake  the  vial  just  before  using  it 
Dose,  from  a half  to  a tablespoonful,  three  or  four  times 
a day.  Opiates  should  be  given,  either  with  this  mix- 
ture, or  at  any  time  when  the  pain  or  frequent  discharges 
demand  their  use.  The  nitrate  of  silver  should  also  be 
given  by  injection  ; for  this  purpose,  from  one  to  two  ta- 
blespoonfuls of  the  above  solution,  with  the  addition  of 
from  thirty  to  sixty  drops  of  laudanum,  if  necessary, 
must  be  easily  and  gently  injected,  so  as  not  to  excite 
the  expulsive  efforts  of  the  bowels. 

Some  practitioners  have  found  the  nitrate  of  silver 
very  efficacious  in  the  treatment  of  obstinate  cases  of 
diarrhoea  in  children.  Dr.  Hirsch,  of  Konigsberg, 
found  it  to  succeed  in  obstinate  cases,  after  other 
ordinary  remedies  had  failed.  “It  proved  specifically 
useful  in  the  diarrhoea  of  newly-wTeaned  infants in 
“the  advanced  stage  of  such  cases,  when  emaciation  was 
extreme,  the  dejections  being  frequent,  fetid,  consisting 
of  a variously  colored,  sometimes  greenish,  or  bloody  mu- 
cous, and  wanting  altogether  the  fecal  character.  When 
aphthous  ulceration  pervaded  the  mouth,  and  when  pros- 
tration was  extreme,  the  action  of  the  nitrate  was  bril- 
liant.” His  manner  of  giving  it  to  them  was  thus  : — 


Mix  well;  dose,  a teaspoonful,  every  two  hours;  and 
an  enema,  containing  a quarter  of  a grain  of  the  salt, 
with  mucilage  and  a little  opium,  was  administered 
The  good  effects  of  this  treatment  were  occasionally  visi- 


1£.  Argentum  nitras,  crystallized,  half  a grain  ; 


Distilled  water 
Gum  mimosas 
White  sugar 


two  ounces ; 
two  scruples ; 
two  drachms. 


DIARRHCEA  AND  DYSENTERY— TREATMENT. 


347 


ble  in  a few  hours,  sometimes  not  until  the  second  day. 
He  pronounces  it  a specific  in  the  diarrhoea  of  infants ; 
and  found  it  almost  equally  efficacious  in  severe  forms  of 
diarrhoea  and  dysentery  occurring  in  adults.  He  admin- 
istered it  to  the  latter  in  pills,  in  doses  varying  from  one- 
twelfth  to  one-twentieth  of  a grain  every  two  hours.  He 
also  gave  enemata,  containing  half  a grain,  or  a grain, 
with  mucilage  and  opium.* 

Dr.  J.  C.  C.  Blackburn,  of  Barnesville,  Georgia,  writes 
as  follows,  in  relation  to  the  use  of  the  strawberry  leaf  : 
“I  have  used  the  strawberry  leaves  in  every  form,  for  the 
cure  of  dysentery  ; but  the  formula  most  desirable  is  as 
follows : R.  one  pound  of  the  green  leaves  ; add  to  them 
one  quart  of  good  French  brandy,  and  boil  to  one  pint. 
Give  of  the  strained  liquor  one  tablespoonful  every  three 
hours,  until  the  disease  in  question  be  relieved  of  its  dis- 
tressing symptoms.  I will  here  add  one  case,  of  the  ori- 
gin of  which  I am  totally  ignorant. 

“ Mr.  B.,  a volunteer  returned  from  Mexico,  was  taken 
with  the  dysentery  at  Matamoros,  last  August,  a year 
ago.  He  was  placed  under  the  direction  of  the  surgeon 
to  the  Georgia  regiment,  who  attended  him  until  he  pro- 
nounced his  case  incurable.  The  patient  afterwards  re- 
covered sufficient  strength  to  accompany  his  regiment  to 
Monterey,  and  thence  to  Vera  Cruz,  where  he  was  again 
prostrated  by  this  disease.  He  reached  home  last  July, 
with  a constitution  almost  broken  down,  and  placed  him- 
self under  my  care.  I resorted  to  the  use  of  every  agent 
within  my  knowledge  for  the  cure  of  his  disease,  but 
without  success.  I at  length  determined  to  try  the 
strawberry  leaves,  as  in  the  formula  above  mentioned. 
He  had  taken  but  ten  tablespoon fuls  when  he  commenced 
to  improve,  and  speedily  recovered.  He  is  now  entirely 


* See  Amer.  Journ.  Med.  Sci.,  April,  1848,  p.  541. 


348 


DYSENTERY— TREATMENT. 


cured , and  able  to  attend  to  the  duties  of  his  calling.  I 
have  used  the  strawberry  leaves  in  many  cases  since, 
with  the  same  happy  results.”* 

A decoction  of  the  bark  of  the  root  of  the  sweet  gum, 
witch  hazel,  butterfly  root,  yellow  root  ( red  shank),  and 
other  indigenous  astringents,  are  sometimes  used  in  do- 
mestic practice.  Balsam  copaiva  and  spirits  of  turpen- 
tine are  recommended  by  some  physicians,  in  chronic 
cases,  especially  when  the  alvine  evacuations  are  chiefly 
mucus. 

In  protracted  cases,  in  which  the  system  has  become 
pale  and  anemic,  it  will  be  advisable  to  give  some  of  the 
more  astringent  preparations  of  iron,  with  opiates  and 
vegetable  astringents;  as,  two  or  three  grains  of  the  sul- 
phate or  carbonate  of  iron,  the  muriated  tincture  of  iron, 
etc.  Some  authors  use  small  doses  of  sulphate  of  zinc, 
or  bluestone,  with  opiates. 

Those  cases  that  are  kept  up  by  an  ulcer  in  the  rec- 
tum, near  the  verge  of  the  anus,  are  said  to  be  cured  by 
the  application  of  nitrate  of  silver  to  the  ulcer. 

In  protracted  chronic  cases,  a broad  flannel  roller  worn 
bound  round  the  belly,  so  as  to  compress  it  firmly,  though 
comfortably,  may  be  of  service. 

Dysentery — Treatment. — The  same  general  plan 
as  is  adapted  to  the  severer  forms  of  diarrhoea,  is  also 
proper  in  dysentery.  The  tormina  and  tenesmus  in  the 
latter,  being  severe,  will  require  the  more  liberal  use  of 
opiates ; therefore,  give  at  once  a good  dose  of  sulphate 
of  morphine  (quarter  to  a half  grain),  or  opium  (one  to 
two  or  three  grains),  or  laudanum  (thirty  to  one  hundred 
drops).  The  opiates  should  be  repeated  several  times  a 
day,  if  necessary.  A free  dose,  given  at  the  commence- 

* South.  Med.  Journ.,  or  South-western  Med.  Adv.,  Oct.  and  Xov.  1847. 


DYSENTERY— TREATMENT. 


349 


ment,  however,  rarely  fails  to  arrest  the  disease  promptly. 
They  control  griping  pains  and  distress  of  the  patient, 
the  frequent  desire  to  go  to  stool,  and  frequent  alvine 
evacuations  ; produce  tranquillity,  ease,  perhaps  sleep ; 
perspiration  ; allay  the  febrile  irritation  and  excitement, 
and  the  individual  is  soon  restored  to  health. 

It  is  pretty  well  known,  among  physicians,  that  Dr. 
Stokes,  of  Dublin,  is  an  advocate  of  the  opiate  treat- 
ment in  dysentery.  From  practical  experience  and 
observation,  being  convinced  of  the  correctness  of  this 
plan,  and  the  erroneous  one  of  calomel  and  purging,  as 
taught  by  Johnson,  and  others,  or,  indeed,  perhaps  I 
should  say,  the  greater  portion  of  the  profession,  it  afford- 
ed me  much  pleasure  to  hear  Professor  Elisha  Bartlett, 
M.  D.,  of  Transylvania  University,  advocate  this  plan, 
after  seeing  Dr.  Stokes.  Professor  Bartlett  stated,  if  my 
recollection  serves,  me  correctly,  that,  while  on  a visit  to 
Europe,  one  of  his  comrades  was  taken  with  dysentery, 
at  Dublin.  Before  prescribing  for  his  friend,  he  went  to 
Dr.  Stokes,  and  asked  him  what  he  must  do  for  him. 
Must  he  give  him  calomel  and  cathartics?  To  which 
Dr.  Stokes  replied  in  the  negative.  “ But,”  said  he, 
“ Cork  him  up “ plug  him  up .”  “ Give  him  opium” 
“ Give  him  opium.”  Dr.  Bartlett  went  back  to  the  hotel 
where  his  friend  was,  and  treated  him  accordingly,  with 
the  result  of  having  him  well  in  a short  time.  The  au- 
thor has  met  with  universal  success  with  the  opiates  and 
other  means  here  laid  down,  the  former  being  the  chief 
reliance,  especially  in  all  acute  cases ; the  addition  of  the 
other  means  here  recommended,  being  necessary  in  the 
chronic  form  of  the  disease. 

In  some  cases  of  dysentery,  the  irritcibiliiij  of  the  sto- 
mach is  so  great  that  it  will  not  even  retain  morphine  or 
other  opiates.  In  these  cases,  a teaspoonful  or  more  of 
laudanum,  with  from  six  to  eight  grains  of  sugar  of  lead, 


350 


DYSENTERY— TREATMENT. 


put  in  an  ounce  of  thin  starch  or  flour  gruel,  should  be 
given  by  injection ; and  repeated  two,  three,  or  four  times 
a day,  or  as  often  as  occasion  requires.  This  should  be 
the  principal  reliance.  A warm  cataplasm  may  be  laid 
over  the  stomach ; or  a mixture  of  warm  spirits,  lauda- 
num, and  a little  water.  If  it  can  be  had,  ice  should  be 
eaten,  to  control  the  irritability  of  the  stomach,  allay 
thirst,  &c. 

In  the  early  stage  of  the  disease,  if  the  febrile  excite- 
ment is  considerable,  a venesection  may  be  necessary, 
especially  in  those  of  full  habit  and  sanguine  tempera- 
ment. A resort  to  this,  however,  as  far  as  the  author’s 
observations  extend,  is  very  seldom  necessary.  A large, 
warm,  light  poultice;  bran  heated  in  an  oven  and  put 
into  a small  sack,  or  a cataplasm,  or  turpentine — the  two 
former  being  preferable — made  large  enough  to  cover  the 
greater  portion  of  the  belly,  will  also  contribute  to  afford 
much  relief  in  many  cases,  especially  those  attended  with 
griping  pains  in  the  bowels. 

After  the  discharges  have  been  arrested  for  a day  or 
so,  and  it  is  thought  advisable  to  procure  a mild  opera- 
tion from  the  bowels,  in  order  to  remove  any  matters  that 
might  prove  a source  of  irritation;  or  which  might  be 
necessary  on  account  of  a febrile  condition  of  the  system  ; 
a dose  of  blue  mass,  castor  oil,  or  rhubarb,  may  be  given, 
with  a little  paregoric ; and  a clyster  of  cool  water,  or 
some  other  mild  one,  may  also  be  resorted  to.  If  the 
skin  be  dry,  and  the  stomach  not  irritable,  two  grains  of 
ipecacuanha,  or  a teaspoonful  of  tincture  of  lobelia,  may 
be  usefully  given  with  the  opiates.  In  some  obstinate 
cases,  relief  has  been  obtained  by  the  use  of  cream  of  tar- 
tar. Dr.  Cheyne  speaks  favorably  of  half  an  ounce  of 
finely  levigated  cream  of  tartar,  given  every  fourth  or 
sixth  hour.  Dr.  Lewis  Shanks,  of  Memphis,  speaking 
of  what  he  terms  “Dysenteric  Diarrhoea,”  which  has  pre- 


DYSENTERY— TREATMENT. 


351 


vailed  for  several  years  at  that  place,  after  mentioning 
the  deleterious  influence  of  mercurial  cathartics,  says : 
“ Unlike  mercurial  and  other  cathartics,  however,  have 
been  the  effects  of  a combination  of  lac.  sulphur,  crem. 
tartar,  and  calcined  magnesia,  in  equal  bulk.  Its  opera- 
tion has  seemed  soothing  and  alterative,  in  changing  the 
morbid  exhalations  to  healthy  secretions ; and  it  is  not 
incompatible,  and  need  not  interfere  with  the  use  of  other 
necessary  remedies,  pro  re  nata,  to  give  this  mixture,  in 
sufficient  quantity,  at  intervals  of  from  two  to  four  hours, 
to  pass  freely  through  the  bowels.”  Dr.  Shanks  speaks 
highly  of  the  influence  of  ice,  both  internally  and  ex- 
ternally. “ The  influence  of  the  ice,  eaten  at  pleasure, 
in  allaying  the  thirst,  and  relieving  the  irritability  of  the 
stomach,  and  especially  its  influence,  rubbed  over  the 
surface  every  twenty  or  thirty  minutes,  followed  by  dry- 
ing and  chafing,  in  relieving  the  blue,  shrivelled,  and 
sudden  relaxation  of  the  skin,  and  the  pouring  out  of 
cold  sweat  — in  restoring  plumpness  and  color,  and 
warmth  and  circulation  to  the  surface,  and  life  and 
healthy  action  to  the  diseased  structure,  deserves  to  be 
recorded  as  additional  evidence  of  its  curative  powers  in 
this  condition  of  the  system.”  Dr.  Shanks  remarks,  that 
“In  the  cold,  clammy  sweat — and  the  feeble,  indistinct 
pulse,  and  the  great  internal  heat  and  oppression  of  col- 
lapse occurring  in  this  form  of  disease,  or  from  cholera 
morbus,  and,  indeed,  from  any  other  cause,  no  remedy 
in  my  hands  has  been  so  safe,  and,  at  the  same  time,  so 
potent,  as  ice,  used  in  this  way.”  The  Doctor,  however, 
also  resorted  to  “ general  and  free  bleeding,  followed  by 
local  depletion — fomentations — stimulating  foot-baths,” 
counter-irritation  by  a large  blister,  dressed  with  emol- 
lient, poultices;  hot  fomentations  to  the  bowels;  opium, 
morphine,  sugar  of  lead;  injections  of  sugar  of  lead,  and 
opium. 


352 


DIARRHCEA  AND  DYSENTERY — TREATMENT. 


In  very  obstinate  chronic  cases,  the  remedies  should 
be  varied;  as  the  same  article,  used  for  some  time,  prob- 
ably loses  its  influence  to  some  degree.  This  may  ex- 
plain the  reason  why  we  often  see  it  stated  that  one 
remedy  has  succeeded,  after  many  others  have  failed. 

For  chronic  dysentery , the  means  recommended  for 
chronic  diarrhoea  are  proper.  Opiates  and  nitrate  of 
silver,  both  by  the  mouth  and  by  injection,  should  not  be 
forgotten,  especially  in  obstinate  cases. 

It  should  be  borne  in  mind  that,  in  the  low,  swampy, 
or  marshy  situations  in  the  South,  these  profluvia  from 
the  bowels  frequently  bear  a certain  relation  to  the  mala- 
rious fevers  of  this  country,  in  which  cases  it  will  be 
necessary  to  give  quinine  with  opiates,  and  probably 
some  of  the  other  means  mentioned  in  this  chapter,  as 
circumstances  may  require  them. 

The  favorable  notice  of  the  matico  ( Piper  angusti folium) 
as  a styptic,  in  stopping  hemorrhages,  as  menorrhagia, 
hematamesis,  hemoptysis,  leucorrhcea,  catarrhus  vesicse, 
and  irritable  bladder,  by  Dr.  Ruschenberger,  may,  here- 
after, induce  the  profession  to  try  its  virtues  in  diarrhoea 
and  dysentery.  During  convalescence  from  chronic 
cases,  a weak  solution  of  sulphuric  acid,  with  some  tonic 
and  astringent  vegetable  infusion,  may  be  of  much  ser- 
vice. 

Diet. — Special  attention  should  be  paid  to  diet  in 
the  treatment  of  diarrhoea  and  dysentery ; this  is  more 
particularly  imperative  in  chronic  forms  of  these  dis- 
eases. Well-boiled  rice,  boiled  milk,  a little  soup,  made 
palatable  with  salt  and  pepper,  tapioca,  farina,  sago, 
panada,  and  the  like,  should  constitute  the  principal  arti- 
cles of  diet.  In  the  chronic  forms,  in  addition  to  the 
above,  chipped  venison  ham,  in  some  cases  bacon  broiled 
on  the  coals,  and  other  easily  digestible,  nourishing  diet 


ASIATIC  CHOLERA. 


353 


which  agrees  well  with  the  stomach,  and  does  not  irritate 
the  bowels,  may  be  used  with  profit  ; the  object  being  to 
nourish  the  debilitated  system,  without  giving  so  much 
as  to  prove  injurious  on  the  one  hand,  while  we  do 
not  starve  too  much  on  the  other.  A rather  abstemious 
diet,  however,  should  be  strictly  observed.  Mutton  suet, 
dissolved  in  warm  milk,  has  been  highly  spoken  of  by 
some  ; a tablespoonful,  four  or  five  times  a day.  Muci- 
laginous drinks  may  be  of  service,  as  solutions  of  gum 
Arabic,  slippery  elm,  althea,  flaxseed,  benne,  pith  of  sas- 
safras, &c.  If  the  system  has  been  very  much  debilitated 
by  a protracted  attack,  on  the  approach  of  convalescence 
agreeable  tonics,  as  an  infusion  of  gentian,  to  which  a 
little  elixir  of  vitriol  or  sulphuric  acid  ought  to  be  added, 
should  be  used  ; gradually  lessening  the  use  of  them,  as 
the  health  becomes  more  perfectly  established.  If  there 
is  attendant  anaemia,  if  the  features  are  of  a pale,  tallowy 
appearance,  some  of  the  preparations  of  iron  should  be 
used.  A little  copperas,  for  instance,  may  be  added  to 
the  infusion  of  gentian,  and  elixir  of  vitriol  or  sulphuric 
acid,  in  these  cases. 


CHAPTER  XXIII. 

ASIATIC  CHOLERA. 

This  epidemic  and  malignant  disease  now  being  preva- 
lent in  this  country,  and  there  being  such  a diversity  of 
opinions,  variety  of  treatment,  and  pretty  general  w^ant 
of  success,  the  author  has  concluded  to  briefly  give  wdiat 
he  considers  the  correct  nature  of  the  disease,  and  the 
rational  mode  of  treatment.  The  consternation,  confu- 


354 


ASIATIC  CHOLERA. 


sion,  and  perturbation  that  it  usually  excites  amongst  the 
people,  appear  to  extend  their  influence  to  physicians ; 
and,  hence,  instead  of  treating  the  disease  according  to 
the  general  principles  of  medicine,  it  seems  that  they  and 
the  people  have  been  seeking  in  an  empirical  manner  for 
some  specific;  and,  notwithstanding  specifics  and  infallible 
cures  have  again  and  again  been  announced,  and  tried  or 
exhibited  time  and  again,  the  cholera,  it  appears,  kills  as 
many,  if  not  more  than  ever,  according  to  the  number 
attacked.  All,  then,  should  learn  the  folly  of  looking  for 
one  particular  medicine  to  cure  the  disease  ; but  study  the 
nature  of  the  malady,  and  be  guided  by  the  general  prin- 
ciples of  medicine  in  its  treatment,  as  in  other  diseases  : 
nor  need  we  expect  to  be  successful,  in  controlling  this 
fell  destroyer,  till  this  course  is  adopted. 

It  is  not  the  author’s  intention  to  give  a history  of  the 
disease,  for  this  of  itself  would  require  a considerable 
volume.  It  is  said  to  have  been  known  in  India  from 
the  earliest  ages,  and  I think  it  highly  probable  that  it  is 
one  of  the  terrible  pestilences  or  plagues  which  are  spoken 
of,  in  ancient  history,  as  being  so  fatal  and  devastating 
to  large  assemblages  of  persons,  collected  together,  either 
for  hostile,  or  religious  or  devotional  purposes.  It  is  said 
to  have  been  described  by  Hippocrates,  near  400  years 
before  the  Christian  era,  and  after  him  by  Aretseus  and 
Celsus,  and  in  1669  by  Sydenham. 

The  delta  of  the  Ganges  appears  to  be  the  principal 
residence  of  the  pestiferous  poison  which  produces  Asia- 
tic cholera,  whence  it  occasionally  extends  to  other  regions 
of  country.  It  has  occasionally  occurred  in  Hindostan  as 
an  epidemic,  ever  since  it  has  been  known  to  the  British. 
In  Upper  Hindostan,  in  1762,  it  is  said  to  have  proved  fatal 
to  a vast  number  of  natives  and  Europeans.  “In  1783, 
it  broke  out  among  the  pilgrims,  who  had  assembled  in  vast 
multitudes,  for  the  purpose  of  ablution,  at  a sacred  spot 


ASIATIC  CHOLERA. 


355 


on  the  banks  of  the  Ganges.  It  is  said  to  have  destroyed 
not  less  than  8,000  of  these  wretched  people  within  the 
brief  period  of  eight  days.  In  addition  to  these  instances 
of  the  prevalence  of  cholera,  it  continued  to  appear  oc- 
casionally in  India,  both  sporadically  and  epidemically, 
from  1762  up  to  the  beginning  of  the  epidemic  of  1817. 
At  Jessore,  a small  town  situated  in  the  delta  of  the 
Ganges,  near  the  tropic  of  cancer,  and  about  one  hundred 
miles  north-east  of  Calcutta,”  ( Lawson ,)  the  Asiatic 
cholera  is  said  to  have  made  its  appearance,  on  the  19th 
of  August,  1817. 

“The  epidemic  spread,  from  the  town  of  Jessore,  in  a 
westward  direction;  and,  early  in  September  following, 
reached  Calcutta,  having  severely  scourged  many  towns 
in  its  march.  The  ravages  of  the  disease  continued  in 
Calcutta  during  the  succeeding  year,  and  it  also  extended 
over  the  entire  province  of  Bengal.  It  spread  in  a north- 
west direction,  following  the  course  of  the  Ganges,  and 
finally  reached  the  Himalaya  mountains,  when  its  march 
in  that  direction  was,  for  a time,  arrested.  Apparently 
manifesting  a preference  for  water  courses,  the  epidemic 
passed  from  the  Ganges  to  the  Nerbudda  river,  and,  fol- 
lowing that  stream  to  the  coast  of  the  Arabian  sea,  it 
reached  Bombay,  in  September,  1818,  where  it  destroyed 
150,000  victims.  The  disease  thus  passed  from  the  Bay 
of  Bengal  to  the  Arabian,  traversing  the  entire  breadth 
of  Hindostan,  a distance  of  about  22°,  in  a period  of  less 
than  one  year  from  its  commencement. 

“ In  the  mean  time  the  disease  spread  southward,  ex- 
tending over  the  entire  Coromandel  coast,  and  invading 
the  islands  of  Ceylon  and  Malacca.  From  Ceylon  it  ex- 
tended, in  1819,  to  the  20th  degree  of  south  latitude,  and 
invaded  the  Mauritius.  And  now  again,  resuming  its 
march  from  Malacca,  it  spread  through  the  healthy  cli- 
mate of  Siam,  invaded  China,  scourged  Canton,  and  other 


356 


ASIATIC  CHOLERA. 


places,  but  did  not  reach  Pekin  until  1821.  In  1820,  it 
arrived  on  the  eastern  coast  of  Africa,  at  Zanguebar. 
Thus,  it  will  be  remarked,  that  the  disease  spread  to 
every  point  of  the  compass,  and  was  not,  as  has  been 
sometimes  supposed,  confined  to  a west  or  north-west 
course.  In  1818,  it  spread  in  three  directions:  north- 
ward to  the  Himalayas,  south  to  Ceylon  and  Mauritius, 
and  westward  to  the  coast  of  the  Arabian  sea. 

“ Continuing  its  northwestern  march,  the  epidemic 
reached  the  shores  of  the  Persian  gulf  in  the  summer  of 
1821 ; it  thence  passed  up  the  Tigris  and  Euphrates,  and 
reached  Bagdad,  in  the  same  year.  It  is  worthy  of  re- 
mark, that  the  disease  did  not  cross  the  deserts  of  Arabia, 
and  that  Mecca,  on  the  western  borders  of  that  country, 
was  not  invaded  until  1831.  From  Bagdad,  it  crossed 
the  desert  to  Aleppo ; and,  in  1823,  reached  the  shore  of 
the  Caspian,  and  also  extended  to  the  Mediterranean. 
At  this  period  it  seemed  to  cease  for  a time,  and  did  not 
extend  beyond  Astrakhan,  a Russian  town,  containing 
forty  thousand  inhabitants,  situated  on  the  Caspian  sea, 
at  the  mouth  of  the  Volga,  in  the  46°  of  north  latitude, 
and  48°  of  east  longitude.  In  looking  back  over  the 
course  of  the  disease  for  six  years,  we  perceive  that  it 
passed  over  90°  of  longitude,  and  68°  of  latitude,  having 
extended  from  the  Mauritius,  in  the  twentieth  degree  of 
south  latitude,  to  the  forty-eighth  degree  of  north  latitude ; 
thus  crossing  the  equator  in  one  direction,  and  in  the 
other  extending  northward  to  the  temperate  zone. 

“ The-  epidemic  having  ceased  for  a time  its  north- 
western march,  after  reaching  the  western  shore  of  the 
Caspian,  at  Astrakhan,  nevertheless  continued  its  ravages 
in  India,  and  ultimately  passing  the  Himalayas,  which 
seemed  for  a time  to  have  arrested  its  progress,  the  dis- 
ease invaded  Chinese  Tartary,  and  devastated  many 
towns. 


ASIATIC  CHOLERA. 


357 


“ After  a delay  in  its  westward  march  for  a period  of 
near  six  years,  epidemic  cholera  resumed  its  progress  in 
that  direction,  and  suddenly  appeared,  in  the  year  1829, 
in  Orenboorg,  a Russian  town,  of  twenty  thousand  inha- 
bitants, situated  on  the  Ural  river.  Reappearing  at  the 
same  time  at  Astrakhan,  at  the  mouth  of  the  Volga,  it 
ascended  that  river,  and  invaded  most  of  the  towns  and 
provinces  in  its  line  of  march.  It  also  spread  through 
Circassia  to  the  river  Don,  which  it  ascended,  and  thus 
Europe  was  fairly  invaded  in  the  year  1829.  Ascend- 
ing the  Volga,  the  epidemic  finally  reached  Moscow  in 
September,  1830.  Continuing  its  march,  St.  Petersburgh 
was  attacked  in  1831 ; thence  it  passed  along  the  coast 
of  the  Baltic,  and  invaded  Berlin,  and  many  of  the  prin- 
cipal towns  of  Prussia.  It  next  followed  the  course  of 
the  Elbe  to  Hamburg,  which  place  it  reached  in  October, 
1831. 

“ We  next  witness  the  disease  in  England.  It  speed- 
ily passed  from  Hamburg  to  Sunderland,  a seaport  town, 
situated  at  the  mouth  of  the  river  Wear,  at  which  place 
it  appeared  on  the  4th  of  November,  1831.  It  reached 
Edinburgh  on  the  27th  of  January,  1832,  and  on  the 
10th  of  February  following  it  invaded  London;  and  in 
March  of  the  same  year  it  reached  France  and  Ireland. 
Calais  is  said  to  have  been  the  first  place  visited  in  France, 
which  occurred  on  the  15th  of  March,  1832,  but  within 
the  same  month  it  appeared  also  in  Paris.  It  spread 
from  Paris  in  every  direction,  but  with  different  degrees 
of  velocity.  Thus,  its  progress  from  north  to  south  was 
about  one  league  in  twenty-four  hours,  while  from  east 
to  west  it  marched  at  more  than  double  that  speed. 

“ From  England,  we  find  this  frightful  disease  extend- 
ing to  the  New  World.  Accordingly,  on  the  8th  day  of 
June,  1832,  it  was  manifested  at  Quebec,  and  on  the 
10th  of  the  same  month  at  Montreal.  On  the  24th  of 


358 


ASIATIC  CHOLERA. 


June,  the  disease  unexpectedly  appeared  in  the  city  of 
New  York;  and  it  is  peculiarly  worthy  of  remark,  that 
all  the  intermediate  towns  and  provinces,  on  the  seaboard, 
including  those  of  New  Brunswick,  Nova  Scotia,  the 
States  of  Maine,  Massachusetts,  and  Rhode  Island,  re- 
mained, up  to  this  period,  entirely  free  from  the  disease. 
It  reached  Philadelphia,  July  5th. 

“ Spreading  westward,  Asiatic  cholera  probably  ap- 
peared in  Cincinnati  on  the  30th  of  September,  1832. 
The  intermediate  country  between  Cincinnati  and  Lake 
Erie  was  unaffected,  at  the  time  it  first  appeared  in  the 
city.  The  disease  appeared  simultaneously  at  Cincin- 
nati Ohio,  Madison  Indiana,  Louisville  Kentucky,  and 
St.  Louis  Missouri.  About  the  last  of  the  same  month 
(October),  the  epidemic  reached  New  Orleans,  but  the 
towns  between  Louisville  and  that  city  generally  re- 
mained free  from  the  epidemic.  The  disease  spread  over 
the  United  States  generally  [many  places  escaping  en- 
tirely], and  in  the  summer  of  1832  invaded  Mexico,  and 
the  following  year  appeared  at  Havana.”* 

South  America  was  not  visited  by  the  disease,  Yucatan 
being  its  limit  in  this  direction. 

“ Returning  apparently  from  America,  cholera  resumed 
its  ravages  in  Europe  ; at  this  time  visited  Spain,  France, 
Rome,  Sicily,  portions  of  Germany,  and,  some  have 
asserted,  destroyed  the  last  victim  on  the  banks  of  the 
Thames. 

“We  are  not  authorized  to  say  that  the  epidemic  of 
1817  has  ever  subsided  ; it  is  true,  its  ravages  have  for  a 
time  abated,  but  it  is  equally  certain  that  it  never  ceased 
to  exist  in  some  portion  of  India.  Within  a few  years, 
however,  the  disease  has  acquired  new  activity,  and  now 
again  appears  as  a wide-spread  epidemic.”* 


* Prof.  L.  M.  Lawson,  M.  D.,  Western  Lancet,  Nov.  1848. 


ASIATIC  CHOLERA— CAUSES. 


359 


In  the  spring  of  1846,  the  cholera  appeared  with  great 
violence  at  Kurrachee,  a considerable  town  situated  in  the 
delta  of  the  Indus.  On  the  1st  of  June,  1847,  it  appeared 
at  Tiflis,  at  Astrakhan  on  the  31st  July,  and  at  Kasan  on 
the  4th  of  October.  The  disease  proceeded  on  to  Mos- 
cow and  St.  Petersburgh,  reaching  the  latter  city  the 
16th  of  June,  1848,  and  Berlin  on  the  15th  of  August, 
pursuing  pretty  much  the  same  course  it  did  in  the  for- 
mer epidemic.  The  ship  New  York  arrived  at  quaran- 
tine, New  York,  on  the  2d  of  December,  1848,  with  cases 
of  cholera  on  board.  The  ship  left  Havre  on  the  9th  of 
November,  with  331  steerage  passengers,  21  in  the  cabin, 
and  30  of  the  crew.  The  first  case  of  cholera  occurred 
on  the  25th,  after  which  it  rapidly  increased.  It  was 
stated  that  many  of  the  emigrants  were  from  Hamburg, 
and  other  parts  of  Germany,  where  the  disease  pre- 
vailed.* 

Soon  after  the  arrival  of  the  cholera  at  Staten  Island, 
it  appeared  at  New  Orleans  with  considerable  virulence, 
and  soon  after,  to  a limited  extent,  at  Mobile,  and  is  at 
this  time  (May  14th,  1849)  prevailing  at  these  places, 
especially  the  former,  and  along  the  Mississippi  river 
and  some  of  its  tributaries,  at  St.  Louis,  Louisville, 
and  elsewhere. 

Causes. — The  cause  of  cholera,  like  that  of  most 
diseases,  is  occult,  and  consequently  has  given  rise  to  a 
variety  of  opinions,  hypotheses,  and  discussions.  It  is 
thought  by  some,  and  with  much  plausibility,  that  the 

*New  York  Courier  and  Enquirer.  See  also  Western  Lancet,  February, 
1849.  Dr.  Whiting,  Health  Officer  at  Quarantine,  Staten  Island,  says : 
“ All  the  persons  who  have  been  attacked,  from  the  first  case  on  board  ship 
to  the  last,  excepting  the  inmates  of  the  hospital,  have  been  from  among 
two  hundred  and  seventy  Germans,  who  have  been  living  in  Havre  and  its 
environs,  where  there  has  not  been  a single  case  of  cholera.  These  persons 
were  originally  from  Germany." 


360 


ASIATIC  CHOLERA— CAUSES. 


essential  cause  of  cholera  never  will  be  discovered.  Who 
knows  the  cause  of  chills  and  fever,  remittent  or  con- 
gestive fever,  measles,  scarlet  fever,  hooping-cough,  ery- 
sipelas, influenza,  and  so  on?  Who  knows  what  electricity 
is ; that  agent  which  plays  so  important  a part  in  the 
operations  of  nature,  and  which  man  has  learned  to  gene- 
rate, control,  and  make  subservient  to  his  will,  to  some 
extent,  by  the  instrumentality  of  which  he  can  converse 
with  his  fellow  man,  though  thousands  of  miles  distant  ? 
The  truth  is,  man’s  knowledge  is  finite.  There  is  a cer- 
tain limit  beyond  which  the  most  gigantic  intellect  cannot 
go ; ultimate  causes  are  beyond  his  comprehension  ; and 
though  an  All-wise  Creator  has  seen  fit  to  limit  his  know- 
ledge, he  has  given  him  the  capacity  to  comprehend 
much;  and  though  the  cause  of  cholera  may  not  be  dis- 
covered, if  its  nature,  if  the  laws  by  which  it  is  governed 
are  fully  ascertained,  mankind  may  be  as  well  off  as 
though  they  had  proceeded  a step  farther,  and  discovered 
the  ultimate  cause. 

I am  inclined  to  believe  that  Asiatic  cholera  is  caused 
by  a poison  which  the  hot,  low,  marshy,  damp  country 
of  the  Ganges,  under  favorable  circumstances,  is  well 
calculated  to  develop;  and  which,  when  produced,  ex- 
tends, by  a sort  of  aerial  fermentation , in  an  atmosphere 
adapted  to  its  propagation ; analogous  to  a little  leaven 
which  leavens  a large  amount  of  dough ; or  a small 
amount  of  yeast  which  affects  a hogshead  or  more  of  sweet- 
ened water,  so  as  to  make  beer,  and  then  vinegar ; and 
that  these  latter,  like  the  cholera  poison,  require  a certain 
time  to  extend  their  influence  throughout  the  dough,  or 
sweetened  water.  According  to  Dr.  Lasegue,  “the  great- 
est rapidity  with  which  the  cholera  has  spread  over  any 
locality,  has  not  exceeded  a rate  of  from  two  hundred  and 
fifty  to  three  hundred  miles  a month.”*  Of  course,  it 


* Amer.  Journ.  Med.  Sci.,  Jan.  1849. 


ASIATIC  CHOLERA— CAUSES. 


361 


may  be  carried  with  greater  velocity,  in  a given  time,  by 
means  of  ships,  steamboats,  &c.  It  is  said  to  require 
from  two  to  four  days,  according  to  the  temperature  of 
the  weather,  for  yeast  to  make  good  beer,  when  put  into 
sweetened  water.  In  relation  to  temperature  also,  the 
cholera-poison  appears  to  be  analogous,  being  somewhat 
impeded  in  its  progress  in  winter,  and  again  extending 
more  rapidly  on  the  approach  of  wrarm  weather.*  After 
it  has  obtained  ingress  into  a large  city,  the  warmth  kept 
up  within  dwellings  may  be  sufficient  to  enable  it  to  pro- 
pagate itself  within  the  city  during  a cold  winter,  while 
its  progress  will  be  impeded  in  its  extension  to  distant 
places.  A ship  or  steamboat,  being  kept  warm  within, 
and  hundreds  of  passengers  being  crowded  and  confined 
together,  and  generally  other  attendant  circumstances,  is 
well  calculated  to  favor  the  propagation  of  cholera. 

It  seems  plausible  to  suppose,  even  were  facts  wanting, 
that  the  cholera-poison  may  be  conveyed  from  one  place 
to  another,  by  means  of  goods  or  clothing ; but  unless  the 
atmosphere  is  favorable  to  its  propagation,  it  might  not 
develop  itself.  If  the  fomites  are  exposed  in  a wTarm, 
humid,  low,  filthy  place,  the  poison  will,  most  probably, 
rapidly  extend  its  influence. 

The  author’s  esteemed  friend,  Professor  L.  M.  Law- 
son,  M.  D.,  remarks:  “ That  the  prevalence  of  cholera  is, 
in  some  manner,  associated  with,  or  influenced  by,  low 
and  damp  localities,  is  conclusively  established  by  the 
concurrent  testimony  of  observers  in  every  country  and 
climate.  In  support  of  this  opinion,  we  may  quote  the 
statement  of  Dr.  Parkes,  who  says,  in  reference  to  the 
epidemic  in  Burmah,  which  occurred  in  1842 : — 

During  this  progress  from  north  to  south,  cholera, 
as  already  stated,  attacked  chiefly,  or  exclusively,  the 

* The  analogy  might  he  extended,  which  the  reader  may  do. 

24 


362 


ASIATIC  CHOLERA— CAUSES. 


towns  and  villages  stationed  in  low,  marshy  places,  on 
the  banks  of  rivers,  or  the  shores  of  the  sea.  It  did  not 
extend  inland,  and  the  Burmans  were  accustomed  to 
escape  it,  by  leaving  their  houses,  and  travelling  into  the 
jungle.  * * * They  universally  stated  that,  though 

they  were  left  without  food  by  this  flight,  and  were  ex- 
posed to  the  burning  noonday’s  rays,  and  to  the  heavy 
tropical  dews  at  night,  yet.  cholera  invariably  left  them 
the  second  or  third  day’s  march  inland. 

“ ‘ Alexander  Thom,  Esq.,  Surgeon  to  H.  R.  Majes- 
ty’s 86th  regiment,  which  was  stationed  at  Kurachee, 
when  that  city  was  invaded  by  cholera  in  June,  1846? 
attaches  great  importance  to  the  states  of  the  atmosphere 
with  reference  to  moisture.  The  prevailing  wind  had 
been  westerly  for  two  months;  the  temperature,  at  the 
time  the  epidemic  broke  out,  stood,  in  the  tents  of  the 
soldiers,  at  98°  to  104°  Fahrenheit;  and  the  quantity  of 
moisture,  says  this  writer,  “ was  greater  than  I ever  saw 
in  any  part  of  the  world,  at  any  season,  the  dew'  point 
being  at  83°,  and  the  thermometer,  in  the  shade,  at  90°, 
the  lowest  range;  even  this,  gives  12.19  grains  of  vapor 
in  each  cubic  foot  of  air.”  And  the  writer  adds  that, 
“contrary  to  what  usually  occurs  in  that  latitude,  the 
weather  wras  characterized  by  light,  weak,  and  unsteady 
winds  or  calms,  instead  of  strong,  steady,  and  cool  winds, 
so  common  in  the  month  of  June,  at  Kurachee.  It  is 
also  stated,  that  the  quantity  of  rain  which  fell  during 
the  prevalence  of  cholera,  was  much  greater  than  is 
usually  witnessed  at  this  season.”  Though  a damp  at- 
mosphere, as  along  the  course  of  rivers,  is  most  favorable 
for  the  propagation  of  cholera,  it  is  said  to  have  prevailed 
in  other  places  when  the  atmosphere  was  not  more  damp, 
or  even  less  so  than  usual.’ 

“During  the  prevalence  of  cholera  in  England,  or 
about  its  commencement,  Dr.  Prout  observed  an  increase 


ASIATIC  CHOLERA— CAUSES. 


363 


in  the  weight  of  the  atmosphere  which  disappeared  as 
the  cholera  subsided.  But  “it  has  been  found  that,  at 
other  places,  during  the  prevalence  of  cholera,  the  atmo- 
sphere was  really  lighter  than  natural.”  {Lawson.) 

There  are  a variety  of  opinions  with  regard  to  the  cause 
of  cholera.  Some  refer  it  to  malaria , or  that  which  is 
supposed  to  produce  the  intermittent,  remittent,  and  con- 
gestive fevers;  others  attribute  it  to  animalculce ,*  electri- 
cal disturbances , carbonic  acid,  &c.  &c.  • Dr.  Cowdel 
supposes  it  to  be  of  vegetable  origin — that  it  “owes  its 
origin  to  the  presence  of  certain  microscopic  fungi,  which 
are,  in  some  mysterious  manner,  generated  and  received 
into  the  animal  system.  As  evidence  of  the  capability 
of  fungi  to  produce  disease  on  a very  large  scale,  if  they 
be  capable  of  such  an  action  at  all,  Dr.  Cowdell  refers  to 
the  observation  of  Fries,  that  a single  one  of  the  reticu- 
larici  maxima  has  produced  ten  millions  sporules ; that 
they  are  exceedingly  light,  and,  consequently,  may  be 
rapidly  diffused  over  a large  extent  of  surface.  It  is  also 
said  that  they  multiply  more  rapidly  after  storms;  seem- 
ing to  have  a meteoric  origin.”  ( Lawson  .) 

It  is  worthy  of  remark  that  cholera  is  generally,  if  not 
always  preceded,  as  a forerunner,  by  influenza  or  diar- 
rhoea. 

Anything  that  has  a tendency  to  debilitate  the  system 
— to  exhaust  the  vital  resources,  renders  it  more  liable 
to  be  attacked  with  cholera;  hence  the  poor,  who  do  not 
have  sufficient  and  proper  nourishment  and  clothing; 
those  who  are  intemperate  and  exposed,  or  otherwise 
enfeebled,  are  more  likely  to  be  attacked,  and  more  apt 
to  succumb.  But  it  must  be  observed,  that  the  opulent 
and  the  temperate  are  also  liable  to  the  disease. 

As  the  cholera  is  most  apt  to  appear  first  in  low,  damp, 


* There  appears  to  he  some  plausibility  in  the  animalcular  theory. 


364 


ASIATIC  CHOLERA— PATHOLOGY. 


dirty,  or  filthy  situations,  this  fact  may  suggest  itself  to 
the  corporate  authorities  of  cities  and  towns,  as  to  what 
extent  they  may  prepare  against  it. 

Pathology. — Be  the  cause  of  cholera  whatever  it  may, 
apparently,  the  chief  primary  morbid  impression  is  made 
on  the  nervous  system,  and  mainly  on  the  organic  and 
spinal  system  of  nerves ; as  is  evinced  by  the  looseness 
of  the  bowels,  nausea,  or  vomiting,  muscular  debility, 
cramps  in  the  legs  or  abdomen,  &c. ; the  brain  usually 
being  but  slightly  affected.  For  aught  we  know,  the 
cholera-poison  may  obtain  ingress  into  the  circulation 
chiefly  by  being  inhaled  into  the  lungs,  and  gradually 
produce  a morbid  change  in  the  blood  before  the  nervous 
symptoms  are  very  manifest;  but  as  the  brain  is  only 
slightly  affected,  it  appears  that  we  should  look  much  to 
the  organic  and  spinal  systems  of  nerves,  these  being  so 
intimately  connected,  it  might  be  difficult  to  determine 
which  is  the  more  affected.  I believe  the  organic  system 
of  nerves  is  generally  considered  as  being  chiefly  in- 
volved. Professor  John  P.  Harrison,  M.  D.,  says  : “ Spas- 
modic, or  Asiatic  cholera,  is  a disease,  primarily,  of  the 
ganglionic  nervous  system ; it  is  a profound  lesion  of  in- 
nervation, or  a pervasive  irritation  of  the  nervous  system 
of  organic  life.” 

The  post-mortem  appearances  observed  at  quarantine, 
Staten  Island,  New  York,  by  Dr.  Whiting,  were  con- 
gestion of  the  lungs,  liver,  spleen,  heart,  kidneys,  and 
brain.  It  is  also  said  that  cholera  may  produce  death 
without  any  structural  or  organic  lesions  being  found 
after  death. 

Though  the  watery  portions  of  the  blood,  commonly 
called  serum , escape  from  the  system,  through  the  bowels, 
it  appears  that  American  physicians  are  at  present  too 
much  disposed  to  overlook  the  condition  of  the  blood,  in 


ASIATIC  CHOLERA— SYMPTOMS. 


365 


their  search  after  organic  lesions,  while  at  the  same  time, 
and  with  plausibility,  many  of  them  regard  cholera  as  a 
nervous  affection  ; the  pathological  condition  of  the  ner- 
vous system  is  probably  too  much  neglected  in  post- 
mortem examinations.  The  difficulty,  minuteness,  and 
skill  required  in  endeavoring  to  ascertain  the  lesions  of 
the  nervous  apparatus,  no  doubt  discourage  many  from 
such  attempts. 

Symptoms. — A confirmed  attack  of  cholera  is  nearly 
always,  if  not  always,  preceded  by  looseness  of  the  bowels 
or  diarrhoea,  of  different,  periods  of  duration,  from  a few 
hours  to  six  or  eight  days  or  more ; and  to  this  condition 
or  stage  of  the  disease  the  term  cholerine  has  been  given. 
Dr.  Bell,  of  Philadelphia,  describes  this  stage  as  follows  : 
the  patient  “ complains  of  lassitude ; has,  frequently,  par- 
tial uneasiness  in  the  region  of  the  stomach,  but  this  not 
to  such  a degree  as  to  alarm  him.  He  has  frequent 
evacuations  from  the  bowels,  from  two  to  a dozen  times  a 
day,  not  attended  with  much  griping.  His  countenance 
is  sharp  and  dark.  He  knows  not  of  this  symptom,  and 
it  is  only  recognizable  to  the  eye  of  experience.  Occa- 
sional nausea  may  oppress  him,  but  this  is  not  a very 
common  occurrence.  These  symptoms  may  continue, 
varying  in  severity,  from  one  to  ten  days,  before  the  second 
stage  of  the  disorder  supervenes.  The  evacuations  at  the 
first  are  generally  of  a dark  brown  or  blackish  hue,  and 
not  unfrequently  bilious.  As  the  looseness  continues, 
they  gradually  become  less  and  less  of  a natural  appear- 
ance, until  they  assume  the  consistence  and  aspect  of 
dirty  water.  Some  headache,  cramp  of  the  fingers,  toes, 
and  abdomen,  and  almost  always  slight  giddiness  and 
ringing  of  the  ears,  accompany  these  symptoms.  Some- 
times an  intervening  two  or  three  days  of  costiveness 
supervenes,  which  is  followed  again  by  the  diarrhoea,  and 


366 


ASIATIC  CHOLERA— SYMPTOMS. 


in  a few  hours  collapse  may  come  on,  and,  in  general, 
nausea  and  vomiting.”  Though  very  rarely  indeed,  if  at 
all,  it  is  said  by  some  that  the  system  may  be  violently 
attacked  with  cholera,  without  being  preceded  by  loose- 
ness of  the  bowels  or  diarrhoea.  I see  it  stated  in  a medi- 
cal journal,  that  death  has  resulted  without  any  evacua- 
tions taking  place  from  the  bowels,  but,  on  dissection,  it 
was  found  that  the  bowels  were  filled  with  such  fluid 
matter  as  is  usually  discharged.  This  retention  is  re- 
ferred to  spasm  of  the  sphincter  ani  muscle.  If  I mis- 
take not,  I heard  my  friend,  Dr.  Clemens,  of  Macon, 
Miss.,  mention  this  circumstance,  not  long  since,  after 
he  returned  from  New  Orleans,  uThere  the  disease  was 
then  prevailing.  It  is  probable  that,  in  these  cases,  the 
diarrhoeal  discharges  manifested  themselves  in  the  early 
stage  of  the  disease;  but,  when  the  disease  becomes  more 
fully  developed,  the  rigid  contraction  of  the  sphincter  ani 
may  prevent  their  escape.  However,  if  a confirmed 
attack  of  cholera  takes  place  without  being  preceded  by 
diarrhoea,  it  must  be  regarded  as  a rare  exception  to  the 
general  manner  of  attack.  The  following  judicious  re- 
marks appear  in  the  London  Medical  Gazette , Oct.  6th, 
1848:— 

“ Experience  has  added  one  fact  of  importance  in  a pro- 
phylactic view  to  our  knowledge  of  this  terrible  pesti- 
lence. As  a general  rule,  the  Russian  practitioners  have 
observed,  that  the  suddenness  of  an  attack  of  cholera  is 
apparent,  and  not  real — it  is,  in  its  severe  form,  the  se- 
condary and  intractable  stage  of  a disease  which,  at  its 
commencement,  is  comparatively  mild  and  tractable ; and 
which,  if  taken  in  time,  may  be  without  difficulty  ar- 
rested by  simple  remedies.  Their  experience  has  led 
them  to  the  conclusion,  that  diarrhoea  is  a precursory 
symptom  of  an  attack  of  Asiatic  cholera;  and  this  diar- 
rhoea may,  or  may  not,  be  attended  with  pain  in  the  ab- 


ASIATIC  CHOLERA— SYMPTOMS. 


367 


domen.  There  is  very  frequently  an  entire  absence  of 
pain — a circumstance  which  leads  to  the  neglect  of 
means  for  remedying  what  appears  to  be  a temporary 
disorder,  but  which  may  turn  out  to  be  the  forerunner  of 
the  fatal  malady.  In  the  diarrhoea  preceding  cholera, 
when  the  pain  has  been  noticed,  it  has  been  simple  un- 
easiness, with  a sense  of  contraction  in  the  bowels.  The 
number  of  evacuations  may  be  from  one  to  six  or  more 
daily ; they  retain,  in  this  stage,  their  fecal  color  and 
odor,  and  are,  in  this  respect,  very  different  from  those 
alvine  discharges,  which  occur  in  the  more  advanced 
stao;e  of  the  disorder : for  these  have  no  fecal  odor  or 
color,  and  resemble  rice-water.  This  simple  diarrhoea 
may,  therefore,  be  considered  to  be  the  commencement 
of  an  attack  of  Asiatic  cholera,  this  name  being  applied 
only  to  the  last  stage  of  the  disease. 

“ The  diarrhoeal  stage  may  last  only  a few  hours — 
two  or  three  days,  or  even  longer.  If  properly  treated, 
the  second  stage  may  be  entirely  averted — if  neglected, 
this  will  commence  suddenly  and  violently  with  those 
severe  symptoms  which  are  commonly  the  precursors  of 
death.  The  suddenness  of  an  attack  of  cholera  is,  there- 
fore, only  apparent — when  inquiry  has  been  made,  the 
milder  stage,  although,  in  some  instances,  of  very  short 
duration,  had  really  existed,  but  was  overlooked. 

“ It  follows  from  the  preceding  observations  that,  nhen 
cholera  is  prevalent  in  a locality , the  slightest  disturbance 
of  the  bowels  requires  attention.  Considering  the  pos- 
sible risk  incurred  by  neglect,  the  fact  that  there  is  only 
one  evacuation  more  than  common,  or  that  the  evacua- 
tion is  more  liquid  than  natural,  should  receive  imme- 
diate notice.  If  the  diarrhoea  really  depend  on  other 
causes,  and  not  on  cholera,  no  mischief  will  follow  from 
its  arrest  by  medicine;  if,  however,  it  depend  on  the 


368 


ASIATIC  CHOLERA— SYMPTOMS. 


cholera-poison,  beginning  already  to  operate  on  the  body 
— then,  by  resorting  to  treatment,  a life  may  be  saved.”* 

Dr.  Hawthorne  says,  that  the  “ pathognomonic  symp- 
toms are,  sudden  debility,  tremors,  numbness,  and  gene- 
ral uneasiness,  pain  of  stomach,  less  or  more  severe,  oc- 
casionally headache,  whiteness,  and  clamminess  of  the 
tongue,  and  precordial  oppression,  succeeded  by  purging, 
vomiting,  and  cramps. 

‘'The  disease  varies  more  or  less  in  its  modes  of  at- 
tack, and  in  the  general  symptoms.  The  following,  how- 
ever, is  the  order  in  which  the  symptoms  generally  man- 
ifest themselves.  The  patient  first  complains  of  general 
weakness  and  languor,  and  what  he  calls  a lightness  in 
the  head,  an  unusual  feeling  over  the  body,  weight  and 
oppression  about  the  heart,  with  a disposition  to  sigh ; 
accompanied  with  a sensation  about  the  stomach  and 
bowels,  which  he  describes  as  a feeling  of  emptiness; 
his  countenance  is  pale  and  his  features  shrunk,  the  fluids 
appearing  to  have  receded  from  the  surface.  These 
symptoms  are  followed  by  a rumbling  sensation  through 
the  bowels.  The  bowels  are  affected  at  intervals  of  a 
few  minutes,  and  the  discharges  become  more  and  more 
fluid,  till  they  present  the  appearance  of  whey,  or  of  rice 
or  barley  water,  becoming,  in  many  instances,  nearly  as 
clear  and  transparent  as  rock  water.  The  relaxation  and 
weakness  increase  with  each  discharge.  The  stomach 
becomes  sick,  and  the  contents  are  thrown  off.  The  pa- 
tient. now  feels  a desire  for  drink,  but  as  soon  as  he  has 
swallowed  it,  it  is  immediately  ejected.  The  sickness 
and  retching  complete  the  relaxation  and  dilatation  of 
the  discharging  vessels,  and  the  whole  fluid  part  of  the 
body  escapes.  In  proportion  to  the  escape  of  the  serous 
or  watery  fluid  from  the  bowels,  the  temperature  of  the 


* See  also  Amer.  Med.  Journ.,  Jan.  1849,  pp.  222-3. 


ASIATIC  CHOLERA— SYMPTOMS. 


369 


body  decreases  till  it  becomes  as  cold  as  dead.  The 
pulse  sinks  in  the  same  proportion,  till  it  ceases  to  be 
perceptible  at  the  wrist.  Cramps  then  come  on  with 
torturing  severity,  and  the  voice  is  hoarse  and  stridulous. 
The  breathing  becomes  laborious,  with  a severe  pain  in 
the  region  of  the  heart;  and  the  patient  tosses  himself 
about  anxiously,  and,  in  vain,  looking  for  relief,  which 
change  of  position  cannot  afford.  A profound  coma 
calms  the  closing  scene.  This  is  a description  of  the 
symptoms  as  they  occur  in  this  form  of  the  disease;  and 
the  whole  process  described,  is,  sometimes,  completed 
within  the  space  of  one  hour. 

“ In  many  cases,  the  symptoms  more  gradually  deve- 
lop themselves.  The  discharges  from  the  bowels  are 
at  longer  intervals — the  first  consisting  of  the  natural 
contents,  the  next  of  a whitish  matter,  which  becomes 
more  gradually  fluid  and  colorless,  till  it  presents  the 
almost  transparent  appearance  already  described. 

“ Such  modifications,  however,  differ  merely  in  de- 
gree. They  are  produced,  no  doubt,  by  peculiarity  of 
constitution,  or  habits  of  life,  or  by  the  greater  or  less  in- 
tensity of  the  existing  cause.”  Dr.  H.  also  says  that, 
in  the  most  malignant  form  of  the  disease,  the  first  dis- 
charges always  take  place  from  the  bowels,  and  the  pa- 
tient does  not  vomit  till  the  disease  has  carried  him  into 
hopeless  collapse,  or  till  he  is  at  least  verging  on  that 
stage.  He  also  observes,  “ that  the  most  rapidly  fatal  at- 
tacks in  cholera  commence  without  any  vomiting,  pain, 
or  cramps,  or  previous  warning  whatever;  and  while, 
under  all  circumstances,  under  all  more  or  less  severe  at- 
tacks of  the  disease,  the  earliest  recourse  ought  to  be  had 
to  remedial  means,  I wish  to  impress  the  importance  of 
being  specially  prompt  when  the  disease  begins  in  this 
most  malignant  and  most  insidious  form,  in  which  a 
delay  of  a very  short  period  might  be  attended  with 


370 


ASIATIC  CHOLERA— SYMPTOMS. 


fatal  results.  I have  seen  much  of  the  fatal  consequences 
of  an  error  of  opinion  in  this  respect,  the  patient  imag- 
ining it  could  not  be  cholera  with  which  he  was  affected, 
because  he  had  no  vomiting,  or  pain,  or  cramps,  when, 
in  point  of  fact,  it  was  the  most  fatal  form  of  the  disease  ; 
and  when  the  vomiting  and  cramps  did  come  on,  they 
were  only  the  fearful  harbingers  of  collapse  and  death.” 
The  urine,  in  cholera,  is  very  scanty,  or  almost  entirely 
suppressed. 

Dr.  Harrison  describes  a case  that  was  brought  from  a 
steamboat  into  town  (Cincinnati),  as  follows:  “He  has 

all  the  characteristic  symptoms  of  cholera  upon  him. 
The  countenance  is  pinched  and  contracted  ; there  is  a 
dark  areola  below  each  eye  ; the  hands  are  blue,  and 
skin  of  the  fingers  corrugated  ; the  breath  is  cold,  as  is 
also  the  tongue;  the  pulse  barely  perceptible;  and  the 
Voice  hollow,  hoarse,  and  feeble.  Here  you  have  the 
rice-water  material  discharged  per  anum.  He  says  that 
he  feels  pain  in  the  thighs,  legs,  and  abdomen ; but  the 
cramps,  with  which  he  has  been  affected,  have  mea- 
surably gone  off — but  the  stomach  is  still  irritable,  and 
the  thirst  very  urgent.  Ferber  came  in  day  before  yes- 
terday, and  was  brought  directly  from  a steamboat  which 
left  New’  Orleans  eight  or  ten  days  ago.  Several  persons 
died  on  the  boat,  of  which  he  was  a hand  ; and  there  ex- 
isted among  others  a strong  tendency  to  cholera,  as  was 
evinced  by  bowel  complaints.  This  poor  fellow  had  been 
laboring  under  diarrhoea  for  several  weeks,  which  was 
allowed  to  go  on  unchecked  by  medicine. 

“ He  has  no  severe  pains  anywhere — slight  soreness  of 
the  muscles,  previously  cramped,  and  his  mind  entirely 
clear — no  coma,  nor  delirium,  or  incoherency  of  thought. 
I find,  on  applying  my  ear  close  to  his  chest,  that  there 
exists  a natural  vesicular  murmur;  the  air  enters  freely 


ASIATIC  CHOLERA— PREVENTION. 


371 


into  all  the  ramifications  of  the  bronchial  apparatus,  and 
into  the  pulmonary  cells.” 

The  mind  is  usually  but  slightly  cr  not  at  all  affected 
in  cholera,  the  patient  commonly  retaining  his  senses  till 
he  is  on  the  very  verge  of  death. 

A reaction , even  to  a febrile  condition , may  ensue  or 
be  brought  about,  and  the  individual  may  recover,  or  he 
may  relapse  again  into  the  collapsed  condition,  and  suc- 
cumb. 

Means  of  Prevention.  — Places  and  habitations 
should  be  kept  as  clean  and  dry  as  possible,  and  well 
aired  ; and  the  people  should  not  suffer  themselves  to 
become  unnecessarily  alarmed,  as  this  may  place  the 
system  in  a condition  to  be  more  easily  affected  with  the 
cholera-poison.  The  people  should  observe  their  regu- 
lar ordinary  mode  of  living,  to  the  avoidance  of  any 
diet  that  is  known  to  disagree  with  them,  or  anything 
to  which  they  are  not  accustomed,  and  avoid  all  debili- 
tating causes  whatever,  the  intemperate  use  of  intoxi- 
cating liquors,  &c. 

A committee,  appointed  by  the  Royal  College  of  Phy- 
sicians, London,  gives  the  following  advice:  “A  state 
of  debility  or  exhaustion,  however  produced,  increases 
the  liability  to  cholera.  The  committee,  therefore,  re- 
commend all  persons,  during  its  prevalence,  to  live  in 
the  manner  they  have  hitherto  found  most  conducive  to 
their  health  ; avoiding  intemperance  of  all  kinds,  and 
especially  the  intemperate  use  of  ardent  spirits,  and 
other  intoxicating  liquors.  A sufficiency  of  nourishing 
food,  warm  clothing,  and  speedy  change  of  damp  gar- 
ments; regular,  and  sufficient  sleep,  and  avoidance  of 
excessive  fatigue,  of  long  fasting,  and  of  exposure  to  wet 
and  cold,  more  particularly  at  night,  are  important  means 


372 


ASIATIC  CHOLERA— PREVENTION. 


of  promoting  or  maintaining  good  health,  and  thereby 
afford  protection  against  the  cholera. 

“ The  committee  do  not  recommend  that  the  public 
should  abstain  from  the  moderate  use  of  well-cooked 
green  vegetables,  and  ripe  or  preserved  fruits.  A cer- 
tain proportion  of  these  articles  of  diet  is,  with  most  per- 
sons, necessary  for  the  maintenance  of  health.  The 
committee,  likewise,  think  it  not  advisable  to  prohibit 
the  use  of  pork  or  bacon,  or  of  salted,  dried,  or  smoked 
meat  or  fish,  which  have  not  been  proved  to  exert  any 
direct  influence  in  causing  this  disease. 

“ On  the  whole,  the  committee  advise  persons  living 
in  districts  in  which  cholera  prevails,  to  adhere  to  that 
plan  of  diet  which  they  have  generally  found  to  agree 
with  them,  avoiding  merely  such  articles  of  food  as  ex- 
perience may  have  taught  them  to  be  likely  to  disorder 
the  stomach  and  bowels.” 

It  may  not  be  amiss  here  to  remark,  that  some  are 
of  opinion  that  the  cholera  is  exclusively  contagious; 
others,  that  it  is  not  contagious,  but  epidemic ; and, 
others  again,  believe  that  it  is  both  contagious  and  epi- 
demic. If  it  be  exclusively  the  one  or  the  other,  I am  of 
opinion  that  it  is  contagious ; that  is,  that  the  poison  is 
conveyed  from  place  to  place,  by  means  of  goods,  ves- 
sels, &c.;  and  that  a person  may  carry  the  cholera- 
poison  from  one  place  to  another  in  his  clothes,  even 
though  he  may  not  be  attacked  himself.  In  corrobo- 
ration of  these  views  and  others,  expressed  under  the 
head  of  causes,  it  is  well  known  that  the  cholera  most 
generally  pursues  the  great  commercial  routes  and  tho- 
roughfares, along  the  humid  course  of  rivers  more  par- 
ticularly ; and  it  may  be,  that  carbonic  acid,  as  along 
water-courses,  and  in  the  larger  cities  and  towns — par- 
ticularly favors  its  propagation.  If  the  views  mentioned 
above  be  correct,  we  can  understand  why  the  cholera 


ASIATIC  CHOLERA— TREATMENT. 


373 


sometimes  breaks  out  simultaneously  in  several  towns, 
without  the  citizens  being  able  to  trace  it  to  contagion : 
as  the  cholera-poison  may  have  been  brought  in  the 
clothes  of  individuals,  who  never  had  the  disease,  but 
who  had  been  in  the  cholera  atmosphere,  or  it  may  have 
been  brought  in  goods;  or,  if  the  distance  is  short,  the 
cholera-poison  may  have  made  its  way  through  the  at- 
mosphere. 

I believe  it  has  been  said  that  a certain  degree  of  tem- 
perature destroys  the  cholera-poison — probably  250°  or 
upwards.  My  recollection  is  not  positive  as  to  the  re- 
quisite amount  of  heat. 

Cholerine,  Treatment  of. — All  modes  of  practice 
that  have  as  yet  obtained  much  notoriety  are  unsatisfac- 
tory, and,  as  the  author  believes,  justly  so,  from  the  fact 
that  they  are  not  adapted  to  the  nature  of  the  disease. 
While  this  is  very  much  to  be  regretted,  it  may  be  ac- 
counted for  on  the  grounds  of  the  various  and  erroneous 
opinions  that  have  been  entertained  in  relation  to  it,  and 
the  general  disposition  to  seek,  in  an  empirical  manner, 
for  some  specific  or  infallible  cure.  In  the  first  place,  the 
nature  of  cholera  should  be  understood ; then  it  should 
be  treated  on  the  general  principles  of  medicine,  accord- 
ing to  the  science,  according  to  common  sense;  and  this 
the  author  will  endeavor  to  briefly  point  out  theoretically, 
while  he  is  not  wanting  in  facts  corroborative  of  his 
views.  Indeed,  the  author  is  of  opinion  that  very  few 
cases  would  terminate  fatally,  if  these  views  were  carried 
out  in  practice. 

For  the  cholerine , the  diarrhoea , or  looseness  of  the  bow- 
els which  precedes  a confirmed  attack  of  cholera,  I would 
recommend  the  treatment  heretof  re  given  for  common 
diarrhoea.  As  soon  as  it  makes  its  appearance,  it  should 


374 


ASIATIC  CHOLERA— TREATMENT. 


be  immediately  arrested  by  opiates,  or  opiates  and  as- 
tringents. For  this  purpose  opium  or  laudanum,  or  pare- 
goric, or  either  of  these  combined  with  astringents,  should 
be  given,  the  dose  proportioned  to  the  severity  of  the 
attack,  and  repeated  as  often  as  the  condition  of  the  pa- 
tient requires  it,  according  to  the  readiness  or  obstinacy 
with  which  the  looseness  of  the  bowels  yield.  Ordina- 
rily, perhaps,  one  or  two  teaspoon fuls  of  paregoric,  or 
from  twenty-five  to  forty  drops  of  laudanum,  or  a grain 
or  two  of  opium  will  be  sufficient.  It  may,  however,  be 
necessary  to  repeat  one  of  these  two  or  three  times  in  the 
course  of  the  day.  The  following  mixture  is  well 

adapted  to  most,  if  not  all  cases  : — 

( ' ' . ■ y • - ' v ..  ( • 

R.  Paregoric  two  fluid  ounces  ; 

Tincture  of  kino,  or  catechu,  or  krameria,  two  fluid  ounces. 

Dose,  two  or  three  teaspoonfuls,  two,  three,  or  four 
times  a day,  or  as  often  as  occasion  requires.  Perhaps 
this  will  rarely  fail  to  check  the  disease.  If,  however,  in 
the  course  of  an  hour,  no  perceptible  check  is  put  to  the 
diarrhoea,  the  dose  should  be  repeated,  or  if  the  looseness 
of  the  bowels  is  considerable,  forty  drops  of  laudanum 
should  be  added  to  a dose  of  the  above  mixture,  and  taken 
immediately.  Four  or  five  grains  of  sugar  of  lead,  with 
thirty  or  forty  drops  of  laudanum,  may  be  given  in  lieu 
of  the  above;  or  any  of  the  astringents  mentioned  when 
treating  of  diarrhoea,  may  be  given  with  laudanum, 
opium,  sulph.  morphine,  or  paregoric.  After  the  loose- 
ness of  the  bowels  is  checked,  they  should  not  be  en- 
tirely  neglected  ; for  if  the  looseness  should  again  return, 
it  should  be  immediately  arrested  by  the  above-mentioned 
means.  In  the  mean  time,  if  the  individual  should  feel 
somewhat  languid  or  dull,  his  system  relaxed  and  de- 
bilitated to  some  extent,  it  mav  be  well  to  take  some 
tonic  medicine,  three  times  a day,  as  a little  infusion  of 


ASIATIC  CHOLERA— TREATMENT. 


375 


gentian,  dogwood,  or  the  like,  or  two  or  three  grains  of 
sulph.  quinine.  If  the  bowels  are  made  costive  from  the 
use  of  opiates,  or  opiates  and  astringents,  wait  two  or 
three  days  for  them  to  move  themselves,  which,  if  they 
fail  to  do,  they  may  be  cautiously  assisted  by  ten  or 
fifteen  grains  of  rhubarb,  or  an  injection  of  cool  water. 
The  diet , in  the  mean  time,  should  be  somewhat  abste- 
mious, though  in  moderate  quantities,  and  sufficiently 
nourishing,  and  of  such  articles  as  are  found  to  agree 
well  with  the  stomach. 

I would  insist  on  all  those  who  feel  interested  for  their 
own  safety,  that  of  their  families,  friends,  or  servants,  to 
pay  particular  attention  to  the  first  manifestations  of  cho- 
lerine, and  immediately  arrest  it  by  the  above  means. 
All  those  who  are  travelling  on  boats  or  otherwise,  or 
residing  where  the  cholera  is  prevalent,  should  prepare 
themselves  with  a bottle  of  the  above  mixture,  and  a vial 
of  laudanum  especially,  and  also  the  other  articles  re- 
ferred to. 

Cholera,  Treatment  of. — When  an  individual  is 
attacked  with  cholera — the  cold  extremities;  cold,  con- 
tracted, perhaps  bluish  surface;  the  copious  and  frequent 
watery  evacuations  from  the  bowels;  the  prostration, 
cramps,  &c.,  are  indexes  to  a condition  of  the  system 
which  most  imperatively  demands  prompt  and  vigor- 
ous treatment,  adapted  to  the  severity  of  the  attack. 
When  a case  is  of  moderate  or  ordinary  severity,  I 
would  recommend  the  immediate  exhibition  of  a tea- 
spoonful of  laudanum,  with  about  twelve  or  fifteen  to 
twenty  or  thirty  grains  of  sulphate  of  quinine.  If  the 
case  is  a severe  one,  I would  also  recommend  that,  at  the 
same  time,  a teaspoonful  of  laudanum  and  six  grains  of 
sugar  of  lead  be  put  into  an  ounce  of  thin  starch  or  flour 
gruel,  or  tepid  water,  and  gently  injected  into  the  rectum. 


376 


ASIATIC  CHOLERA-TREATMENT. 


The  quinine  should  be  repeated  in  from  three  to  five 
hours,  and  the  dose  reduced  to  eight  or  ten  grains,  if 
the  previous  one  of  quinine  and  laudanum  has  had 
the  desired  effect  in  bringing  about  reaction,  &c.  The 
dose  of  laudanum  at  this  time  should  also  be  reduced 
or  omitted,  if  the  previous  one  has  had  the  desired  effect 
in  assisting  to  bring  about  reaction,  in  arresting  the  dis- 
charges from  the  bowels,  or  if  it  has  produced  consider- 
able narcosis ; under  these  circumstances,  it  should  be 
deferred  till  its  use  is  indicated.  If  these  medicines  be 
ejected  from  the  stomach  or  rectum,  they  should  be  re- 
peated in  a minute  or  two.  In  the  more  violent  cases, 
there  appears  to  be  much  difficulty,  in  many  of  them,  to 
get  medicines  to  remain  on  the  stomach.  When  this  is 
the  case,  a grain  of  sulphate  of  morphine  should  be  dis- 
solved in  a tablespoonful  of  cold  water,  and  taken  some 
ten  minutes  before  the  administration  of  twenty  or  thirty 
grains  of  quinine.  Two  teaspoonfuls  of  laudanum,  with 
thirty  or  forty  grains  of  quinine,  should  also  be  immedi- 
ately given  by  injection,  first  being  mixed  with  two  or 
three  ounces  of  thin  starch  or  flour  gruel.  If  medicines 
cannot  be  retained  in  either  of  these  ways,  by  the  stomach 
or  rectum,  a tolerably  large  blister,  say  four  or  six  inches 
square,  should  be  immediately  made  over  the  region  of 
the  stomach,  by  means  of  acetic  acid,  ammonia,  hot 
water,  or  otherwise,  and  a grain  or  two  of  morphine,  and 
thirty  or  forty  grains  of  quinine,  mixed  with  some  thin 
paste,  made  of  starch  or  flour  and  water,  immediately  ap- 
plied to  the  blistered  surface.  The  quinine  should  thus 
be  sufficiently  diluted,  so  as  not  to  produce  pain. 

In  addition  to  the  above,  for  the  gastric  irritability  and 
thirst,  the  patient  should  eat  ice , pretty  frequently  re- 
peated, and  in  rather  liberal  quantities,  if  he  desires  it, 
but.  not  to  such  an  extent  as  to  overload  the  stomach  or 
to  fill  it  with  water,  and  thereby  produce  vomiting.  But 


ASIATIC  CHOLERA— TREATMENT. 


377 


I believe  it  is  more  safe  to  err  in  giving  too  much  than 
not  enough ; if  the  water  is  thrown  up,  the  stomach  will 
be  in  a good  condition  for  the  reception  of  the  ice.  I 
would  insist  that,  wherever  ice  can  be  obtained,  its  free 
use  be  not  neglected.  If  it  cannot  be  obtained,  the 
coldest  and  best  water  should  be  used.  If  ice,  taken 
alone,  affects  the  stomach  unpleasantly  in  the  cold,  or 
collapsed  stage,  it  should  be  crushed,  and  taken  in  some 
brandy,  tincture  of  asafetida,  or  the  like.  In  the  severer 
cases,  in  addition  to  the  above,  and  simultaneously 
with  it,  I would  recommend  the  exhibition  of  stimu- 
lants, to  bring  about  or  assist  in  bringing  about  reaction; 
as  a dessertspoonful  of  sulphuric  ether,  given  in  half  a 
glass  of  sweetened  water,  briskly  stirred,  and  to  be  im- 
mediately drunk.  Camphor  and  French  brandy,  port 
wine,  or  other  spirits,  may  be  used  instead  of  the  ether ; 
the  latter,  however,  being  preferable,  as  its  action  is  more 
prompt.  A dessertspoonful  or  two  may  also  be  poured 
on  a folded  handkerchief,  and  held  to  the  mouth  and  nos- 
trils, in  cases  attended  with  pain  and  cramps,  so  as  to  be 
inhaled,  which  will  hasten  its  influence  on  the  system. 

The  quinine  should  be  repeated  every  three  or  five 
hours,  in  doses  proportioned  to  the  severity  of  the  attack 
and  the  influence  of  the  remedies.  In  the  intervals  of 
giving  the  quinine,  a dose  of  sugar  of  lead  (three  or  four 
grains),  kino  (twenty  grains),  catechu  (thirty  grains), 
krameria  (the  tincture,  two  fluidrachms),  creasote  (one 
drop),  or  the  like,  should  be  given.  The  copious  liquid 
evacuations  from  the  bowels  must  be  arrested,  and  reaction 
and  warmth  restored  to  the  general  surface,  and  the  tone 
of  the  nervous  system  braced  or  increased,  or  the  patient 
will  die. 

As  soon  as  an  individual  is  attacked  with  cholera,  he 
should  immediately  be  put  to  bed,  and  covered  with  two 
or  three  blankets. 

25 


378 


ASIATIC  CHOLERA— TREATMENT. 


As  to  external  medication , in  endeavoring  to  bring 
about  reaction,  perhaps  nothing  is  superior  to  a dozen  or 
two  ears  of  corn,  just  taken  out  of  hot  water,  and  applied 
about  the  body  and  extremities.  Hot  rocks,  bricks,  irons, 
bottles  filled  with  hot  water,  or  other  similar  means  may, 
however,  be  resorted  to,  when  the  hot  corn  is  not  con- 
venient; and  the  general  surface  should  be  rubbed  assi- 
duously with  warm  spirits  and  pepper,  or  mustard,  or 
warm  spirits  of  turpentine.  Frictions,  particularly 
along  the  course  of  the  spine,  as  well  as  to  the  cold 
extremities  and  surface,  should  receive  attention.  If 
convenient,  and  if  it  can  be  done  without  the  patient 
having  to  raise  up,  plunging  the  feet  and  legs  into  w^ater 
as  hot  as  it  can  comfortably  be  borne,  to  which  pepper  or 
mustard  has  been  added,  may  be  of  some  service ; but, 
if  the  hot  corn  is  used,  it  will  supersede  the  necessity 
of  this,  at  least  to  a great  extent. 

It  is  probable  that  the  cold  dash , under  some  circum- 
stances, as  is  recommended  in  some  cases  of  congestive 
fever,  in  cases  attended  with  great  restlessness,  oppres- 
sion, and  anxiety,  might  be  of  much  service  in  bringing 
about  reaction,  and  otherwise  contributing  to  the  relief 
of  the  patient. 

After  reaction  has  been  brought  about,  I would  recom- 
mend the  continuance  of  the  quinine,  in  doses  of  from 
four  to  six  or  eight  grains,  three  or  five  times  a day,  for 
several  days;  and  laudanum,  from  one  to  three  times  a 
day,  or  as  circumstances  require,  to  prevent  relapse  and 
insure  recovery.  If  a febrile  condition , to  any  extent, 
should  exist  at  this  time,  a few  grains  of  blue  mass, 
or  five  to  eight  grains  of  calomel,  once  or  twice  a day, 
may  be  advisable.  If  the  febrile  reaction  should  be  too 
great  (which,  however,  is  rarely  to  be  expected),  with 
too  much  determination  to  the  head,  it  may  be  controlled 
by  pouring  cold  water  freely  over  the  head  and  neck ; 


ASIATIC  CHOLERA— TREATMENT. 


379 


and,  if  the  general  surface  be  hot  and  dry,  it  should  be 
sponged  occasionally  with  cool  or  tepid  water.  Blood- 
letting is  rarely  necessary,  and,  when  resorted  to,  should 
be  practiced  with  great  caution.  During  this  febrile 
condition,  the  patient  should  also  be  allowed  ice  or  cold 
water  to  allay  thirst,  taken  in  moderate  quantities  fre- 
quently repeated. 

If  acidity  of  the  stomach  occurs,  which  is  said  often  to 
take  place  the  second  day,  in  malignant  attacks,  the  in- 
fusion of  a little  bicarbonate  of  soda  or  potash,  in  a mix- 
ture of  w’ater  and  an  equal  quantity  of  compound  tinc- 
ture of  cardamoms,  or  tincture  of  cinnamon — or  these 
antacids  may  otherwise  be  taken — will  fulfil  this  indi- 
cation, as  these  will  neutralize  the  superabundant  acid. 
Ammonia,  or  other  alkalies,  may  be  used  for  the  same 
purpose;  but  it  should  be  borne  in  mind  that  ammonia 
is  stimulant,  and  where  there  is  febrile  excitement,  un- 
less it  be  of  a low  grade,  its  use  is  contraindicated. 

If  quinine  is  not  at  hand,  or  to  be  had,  give  strong 
decoctions  or  tinctures  of  the  following  articles  in  its 
stead,  namely  : Peruvian  bark,  dogwood,  cherry  tree, 
willow,  poplar,  the  bruised  leaves  of  the  American  holly, 
gentian,  salicine,  chiniodine,  quassia,  or  other  bitter 
tonics  that  are  used  in  ague  and  fever. 

The  condition  of  the  system  imperatively  demands 
that  nourishment  should  receive  special  attention.  Too 
much  diet,  or  that  which  the  stomach  cannot  digest,  or 
which  disagrees  with  it,  must  not  be  given,  as  such  a 
course  would  have  a tendency  still  more  to  depress  and 
debilitate  the  system.  Wine  whey;  chicken,  beef,  or 
mutton  soup,  or  the  like,  ought  to  be  regularly  given 
every  three  or  four  hours ; which  articles  should  be  made 
palatable  and  cordial  with  salt,  pepper,  and,  in  cases  of 
great  prostration,  the  addition  of  a little  wine.  Rice  and 
chicken  soup  is  probably  as  good  as  any  other  prepara- 


380  ASIATIC  CHOLERA— TREATMENT,  REMARKS  ON. 

tion  of  diet.  Boiled  milk,  sago,  tapioca,  panada,  and  the 
like,  may  also  answer  a good  purpose  as  nutrients. 

Remarks. — It  is  well  known  that  different  articles 
may  induce  a similar  condition  of  the  system  ; thus,  cold 
water,  drank  when  overheated,  may  produce  colic;  so 
also  may  undigestible  food  taken  into  the  stomach. 
Overfatigue  and  starvation,  or  poisonous  substances  in- 
haled, or  taken  into  the  stomach,  may  produce  a similar 
febrile  condition  of  the  system  ; and  so  also  may  a splin- 
ter stuck  under  the  nail,  or  in  the  flesh.  A severe  shock 
to  the  body  may  produce  chilliness  and  paleness,  analo- 
gous to  the  first  stage  of  an  intermittent  or  congestive 
attack  of  fever.  And,  be  the  cause  of  cholera  and  con- 
gestive chills  the  same  or  not,  the  symptoms  of  the  for- 
mer are  as  analogous  to  those  of  one  form  of  congestive 
chill , as  those  of  any  two  diseases,  or  even  the  same  dis- 
ease in  different  persons;  and,  in  my  humble  opinion,  it 
should  be  treated  on  the  same  general  principles.  In 
this  form  of  congestive  chills,  there  are  copious  watery 
evacuations  from  the  bowels,  cold  extremities,  coldness, 
and  shrinking  of  the  general  surface,  so  that  rings  on  the 
fingers  become  loose;  there  are  great  prostration, anorexia; 
cramps  of  the  stomach,  calves  of  the  legs,  abdomen,  &c. : 
vomiting,  thirst,  great  restlessness;  the  pulse  small  and 
weak,  or  perhaps  scarcely  or  not  at  all  perceptible  at 
the  wrist;  the  features  are  contracted  ; and  the  extremi- 
ties, and  general  surface  in  some  cases,  become  bluish, 
analogous  to  that  which  is  observed  in  the  collapsed  or 
blue  stage  of  cholera.  Indeed,  the  symptoms  are  almost, 
or  quite  identical,  with,  perhaps,  the  exception,  that,  in 
the  severest  forms  of  cholera,  they  may  be  somewhat 
more  intense  than  is  usually  the  case  in  the  above-men- 
tioned variety  of  congestive  chill.  This  form  of  con- 
gestive chill  is  not  only  well  known  to  the  physicians 


ASTATIC  CHOLERA— TREATMENT,  REMARKS  ON.  381 

of  the  southern  and  southwestern  States,  those  of  India 
and  elsewhere,  but  it  appears  to  have  been  known  to  the 
ancient  Greeks. 

In  corroboration  of  the  plan  of  treatment  I have  laid 
down,  and  the  remarks  already  made,  I may  mention 
that, "from  what  I have  been  able  to  learn,  the  quinine  and 
opiate  treatment  adopted  in  some  portions  of  the  south- 
western States,  when  the  epidemic  cholera  visited  this 
country  before,  though  no  doubt  far  too  feebly  practiced, 
was  eminently  successful.  And  though  I disapprove  of 
the  plan  of  treatment  recommended  by  Dr.  Cartwright, 
of  Natchez,  Mississippi,  and  which,  indeed,  has  already 
proved  to  be  unsuccessful,  the  following  remarks  by  him, 
published  in  the  New  Orleans  Medical  and  Surgical 
Journal , tend  to  corroborate  the  remarks  I have  made 
above:  “The  practice  that  was  found  to  be  the  most 
successful  in  the  southwest,  in  the  epidemic  Asiatic  cho- 
lera, has  never,  to  this  day,  been  dignified  writh  any  no- 
tice (except  a trivial  one  in  Boston),  in  any  medical  book 
or  medical  journal  since  published. 

“ Dr.  Bell,  in  his  elaborate  chapters  on  cholera,  men- 
tions almost  every  practice  and  mode  of  treatment,  ex- 
cept that  which  experience  in  his  own  country  proved  to 
be  most  successful.  It  was  an  American  practice,  built 
on  a Grecian  precedent,  but  it  happened  to  be  directly 
contradictory  to  the  physiological  and  fashionable  batch 
of  theories,  which  were  last  imported  from  Europe.  It 
is  a practice  not  only  successful  in  arresting  watery  eva- 
cuations in  cholera,  but  also  in  congestive  fever,  with 
almost  as  much  certainty  and  safety  as  quinine  arrests 
an  intermittent.  It  was  only  noticed  in  Boston,  to  sink 
its  author  in  the  estimation  of  the  profession,  as  one  act- 
ing without  authority,  and  setting  all  law  and.  gospel  in 
medicine  at  defiance.  The  translation  of  Hippocrates 
into  the  English  language  will  prove  to  the  medical  pro- 


382 


ASIATIC  CHOLERA— CONCLUDING  REMARKS. 


fession,  that  the  author  has  the  soundest  philosophy,  and 
the  very  highest  authority,  for  the  objectionable  remedies 
he  used  in  cholera,  and  still  uses  in  congestive  fevers,  of 
any  known  in  medicine.” 

In  conclusion,  I will  refer  to  a fact  communicated  to 
me  by  a gentleman  whose  acquaintance  I recently  made 
at  Tuscumbia,  Alabama,  and  who  is  not  a physician. 
He  stated  that,  while  on  a visit  to  New  Orleans,  during 
the  recent  epidemic,  a friend  of  his  w?as  in  the  last  stage 
of  cholera;  that  is,  he  was  cold,  his  features  contracted, 
pulseless,  and  apparently  almost  lifeless.  It  struck  him 
that  this  condition  was  analogous  to  that  of  a congestive 
chill;  and,  knowing  very  large  doses  of  quinine  to  be 
successful  in  the  latter,  he  concluded  to  resort  freely  to 
it  in  the  case  of  cholera  before  him.  He  threw  it  into 
the  man  in  very  large  doses,  without  being  particular  as 
to  the  amount,  so  he  gave  enough,  and  in  addition,  used, 
external  frictions  with  mustard,  &c.  It  was  not  long 
before  the  pulse  could  be  felt  at  the  wrist,  warmth  was 
restored  to  the  general  surface,  and  the  patient  soon  reco- 
vered. It  should  be  mentioned  that  the  other  remedies 
had  no  influence,  apparently,  till  the  quinine  increased 
the  vitality  of  the  system. 

I notice,  in  the  May  number  of  the  New  Orleans 
Medical  Journal , that  Gilman  M.  Peck,  M.D.,  after 
using  the  usual  articles  (for  they  are  not,  perhaps,  en- 
titled to  the  appellation  of  remedies)  till  his  patient  was 
nearly  dead,  gave  him  at  once  twenty  grains  of  quinine, 
with  twenty-five  grains  of  calomel,  with  the  happy 
result  of  soon  seeing  returning  warmth,  and  rapid  im- 
provement in  all  the  symptoms,  and  a speedy  reco- 
very. Who  can  hesitate  to  attribute  this  to  the  quin- 
ine? The  quinine  was  also  subsequently  repeated, 
several  times.  In  this  case,  the  external  irritating  or 
stimulating  applications  had  no  perceptible  effect  till  the 


CROUP. 


383 


vitality  of  the  general  surface  was  increased  by  the 
quinine. 

July  6,  1849.-— Since  writing  the  above,  the  cholera 
has  appeared  in  New  York,  Philadelphia,  and  several 
other  cities  of  the  United  States.  It  is  prevailing  with 
great  malignity  at  Cincinnati  and  St.  Louis;  and  also 
in  Paris,  France. 


CHAPTER  XXIV. 

CROUP.  (CYNANCHE  TRACHEALIS.) 

It  was  not  my  intention  to  write  a chapter  on  Croup ; 
but  it  has  occurred  to  me  that  this  book  will  fall 
into  the  hands  of  many  who  may  be  distantly  situ- 
ated from  a physician.  When  this  is  the  case,  the 
disease  often  being  rapid  in  its  progress,  the  little  suf- 
ferer is,  in  many  cases,  either  dead  before  the  aid  of 
a doctor  can  be  procured,  or  perhaps  beyond  the  power 
of  the  healing  art  when  he  arrives.  These  circum- 
stances, and  the  sometimes  insidious  attacks,  wThich  do 
not  sufficiently  early  attract  the  attention  of  parents, 
are  well  known,  by  practitioners  in  the  thinly  settled 
regions  of  the  South,  to  be  the  causes  of  not  unfre- 
quent fatal  terminations  in  croup.  From  these  con- 
siderations, and  in  order  that  this  work  may  be  more 
useful  to  the  public,  I have  noticed  this  disease  more 
for  their  benefit  than  for  that  of  physicians  (except 
young  ones  and  students),  who,  it  is  presumed,  are  gene- 
rally as  familiar  with  the  nature  and  treatment  of  the 
disease  as  is  the  author. 


384 


CROUP— SYMPTOMS. 


Croup  is  sometimes  called  by  the  old  women,  “bold 
hives,"  or  “ hives  they  also  call  some  breaking  out  on 
the  skin,  or  some  cutaneous  affections,  “hives;"  as,  for 
instance,  the  papular  eruption  of  very  young  infants, 
known  among  physicians  by  the  name  of  strophulus. 
This  is  unfortunate,  as  this  uncertain  nomenclature 
often  leads  many  of  them  to  give  remedies  that  are  not 
adapted  to  the  one  or  the  other  affection. 

Perhaps  I cannot  better  describe  an  attack  of  croup 
than  by  the  following  extract  from  Dr.  Eberle’s  work  on 
the  practice  of  medicine. 

“ Symptoms. — This  disease  sometimes  comes  on  sud- 
denly, and  acquires  the  utmost  degree  of  violence  in  the 
course  of  a few  hours.  More  commonly,  however,  its 
approach  is  gradual,  the  first  symptoms  being  those  of 
ordinary  pulmonary  catarrh.  A dry  and  hoarse  cough, 
with  slight  difficulty  of  breathing,  and  a change  of  the 
voice,  are  generally  the  first  intimations  of  its  invasion. 
This  very  peculiar  hoarse  and  rough  cough,  with  its 
accompanying  slightly  oppressed  breathing  continues 
sometimes,  with  occasional  remissions,  for  several  days 
before  the  disease  assumes  its  characteristic  form  and 
violence.  More  or  less  febrile  excitement  is  generally 
present  from  the  very  commencement  of  the  disease. 
Sooner  or  later  the  respiration  becomes  more  difficult 
and  distressing ; the  febrile  reaction  rises  higher ; the 
voice  becomes  indistinct,  whispering,  or  annulled  ; slight 
pain  and  uneasiness  are  felt  in  the  larynx,  and  the  cough 
becomes  more  sonorous.  The  disease  now  advances 
rapidly  to  its  state  of  full  development,  and  all  the  symp- 
toms acquire  a most  alarming  and  distressing  degree  of 
violence.  The  countenance  is  flushed;  the  eyes  promi- 
nent, injected,  and  heavy;  the  pulse  frequent,  tense,  and 


CROUP— SYMPTOMS. 


385 


quick ; the  skin  dry  and  hot ; and  the  respiration  ex- 
tremely difficult  and  anxious.  Inspiration  is  especially 
difficult,  and  accompanied  with  a very  peculiar  ringing 
or  stridulous  sound,”  which  has  been  likened  to  the 
crowing  of  a young  cock,  or  the  barking  of  a dog.  “The 
cough,  at  this  time,  is  often  quite  dry  ; but,  in  some  in- 
stances, there  is  a copious  and  very  tenacious  albuminoid 
fluid  secreted  in  the  larynx  and  trachea,  from  the  very 
onset  of  the  disease;  and,  in  all  cases,  this  viscid  secre- 
tion occurs  in  the  advanced  stage  of  the  malady.  If  the 
disease  be  not  checked  in  its  violence  and  progress,  the 
breathing  acquires  at  last  a degree  of  oppression  inex- 
pressibly distressing ; the  little  patient  manifests,  in  the 
expression  of  its  countenance  and  actions,  the  utmost 
degree  of  anguish  and  suffering;  the  head  is  thrown 
backwards,  and  the  mouth  kept  open  ; the  eyes  are  half 
closed,  or  cast  about  with  an  imploring  expression  for 
relief;  the  voice  is  extinct;  the  lips  livid,”  and,  perhaps, 
lividity  also  appears  around  the  eyes,  and  on  a portion  of 
the  fingers  about  the  nails;  “the  face  pale,  and  covered 
with  large  drops  of  sweat,”  in  many  instances;  “sen- 
sibility rapidly  diminishes;  slight  coma  ensues  ; the  ex- 
tremities become  cold  and  clammy;  and,  finally,  breath- 
ing stops,  and  closes  the  agonizing  scene. 

“ Such  are  the  ordinary  course  and  symptoms  of  this 
frightful  malady.  Much  diversity,  however,  occurs  in 
relation  to  the  degree  of  violence  and  rapidity  of  these 
phenomena.  In  some  instances,  not  more  than  a few 
hours  elapse  between  the  commencement  and  fatal  ter- 
mination of  the  disease.  In  other  cases,  the  symptoms 
proceed  slowly  to  their  acme,  and  the  disease  is  protracted 
for  many  days,  and  occasionally,  even  for  several  weeks, 
assuming  a chronic  character,  without,  perhaps,  having 
at  any  time,  manifested  a very  alarming  degree  of  vio 


386 


CROUP— SYMPTOMS. 


fence.  The  ordinary  period  occupied  by  the  disease  is 
from  two  to  five  days.” 

In  most  instances,  occurring  in  the  South,  perhaps 
there  is  not  that  degree  of  febrile  excitement  described 
by  more  northern  authors  ; the  pulse  not  being  so  hard 
and  tense,  though  increased  in  frequency.  In  most  cases 
there  is  a copious,  nearly  transparent,  semi-transparent, 
viscid  mucus  secreted,  which  greatly  interferes  wTith  re- 
spiration, and  which  may  cause  the  death  of  the  little 
sufferer,  unless  it  be  relieved  of  it.  In  some  instances,  a 
false  membrane  is  formed  in  the  windpipe,  which  is  apt 
to  produce  death.  In  these  cases,  the  cough  and  respi- 
ration are  dry , instead  of  humid,  as  in  the  above  variety. 
There  is  exacerbation  in  the  difficulty  of  breathing; 
that  is,  it  is  sometimes  worse,  and  then  again  there  is 
some  temporary  amelioration : it  is,  also,  usually  worse 
once  a day,  in  those  cases  that  last  for  several  days,  mani- 
festing a periodical  recurrence,  which  is  most  apt  to  take 
place  in  the  early  part  of  the  night,  like  the  bronchitis  of 
children. 

Spasmodic  croup  ( Laryngismus  stridulus)  is  more 
strictly  of  a periodical  nature  than  the  above,  the  pa- 
roxysms usually,  if  not  invariably,  making  their  appear- 
ance at  night.  Professor  Dunglison  describes  this  form 
or  variety  of  croup  as  follows : “ A disease  of  infants, 
characterized  by  suspension  of  respiration  at  intervals ; 
great  difficulty  of  breathing,  especially  on  waking,  swal- 
lowing, or  crying,  ending  often  in  a fit  of  suffocation 
with  convulsions.  The  ear,  on  auscultation,  at  a dis- 
tance from  the  chest,  detects  an  incomplete,  acute,  hiss- 
ing inspiration,  or  rather  cry ; whilst  the  expiration  and 
voice  are  croupal,  both  at  the  accession  and  termination  of 
the  paroxysm.  The  heart’s  action  has  been  observed  to 
be  distinct  and  feeble,”  the  pulse  small  and  contracted. 

“These  symptoms  are  often  accompanied  by  rigidity 


CROUP— PATHOLOGY. 


387 


of  the  fingers  and  toes ; the  thumb  being  frequently 
drawn  forcibly  into  the  palm  of  the  clinched  hand.” 
Spasmodic  croup  makes  its  appearance  suddenly,  being 
seldom  preceded  by  catarrhal  symptoms,  or  only  for 
a short  time.  In  this  form  of  croup,  the  child  may  have 
no  fever,  or  but  to  a slight  degree;  or,  indeed,  its  extre- 
mities may  be  cool ; it  may  be  relieved  of  an  attack  one 
night,  run  about,  appearing  well,  or  nearly  so,  the  ensu- 
ing day,  and  be  attacked  again  the  next  night,  and  soon. 

Pathology. — The  first  variety  of  croup  noticed  above 
is  regarded  as  a highly  inflammatory  disease,  the  local 
affection  consistingof  inflammation  of  the  lining  (mucous) 
membrane  of  the  windpipe  (trachea).  It  is  the  opinion 
of  some  that  this  inflammation  usually,  or  often,  com- 
mences about  the  tonsils,  fauces,  or  larynx,  and  descends 
into  the  windpipe,  and  frequently  into  the  bronchia ; 
thus,  in  such  cases,  producing  bronchitis  at  the  same 
time,  which  renders  the  affection  vastly  more  dangerous. 
At  the  onset,  perhaps,  the  extent  to  which  the  nervous 
system  or  cerebro-spinal  axis  is  involved,  is  too  much 
overlooked. 

The  second  variety , spasmodic  or  nervous  croup , may, 
perhaps,  wuth  propriety  be  regarded  as  a nervous  affection, 
depending  on  irritation  of  the  cerebro-spinal  axis,  which 
may  be  primary,  or  caused  by  sympathy  from  irritation 
of  the  stomach  and  bowels,  Su\ 

“ It  may  be  observed,  that  the  immediate  cause  of  the 
distressing  difficulty  of  respiration,  and,  finally,  of  death, 
consists  in  an  obstruction  to  the  passage  of  the  air  into 
the  lungs.  The  circumstances  which  cause  the  exclusion 
of  the  air  from  the  lungs,  consist  either  in  a spasmodic 
closure  of  the  glottis,  or  in  an  occlusion  of  this  aperture 
by  tumefaction  of  its  sides,  or  by  the  formation  of  false 
membrane  or  a mass  of  concreted  lymph,  or,  finally,  by 


388 


CROUP— PATHOLOGY. 


an  excessive  quantity  of  a very  ropy  and  viscid  mucus 
closing  up  the  passage.  Death  is  also  sometimes  the  im- 
mediate consequence  of  an  effusion  into,  and  consequent 
choking  up  of  the  bronchial  cells,  a mode  of  termination 
which  almost  always  occurs  when  the  inflammation 
descends  into  the  bronchial  ramifications.  Spasmodic 
contraction  and  closure  of  the  glottis  may  be  caused  by 
irritation  excited  by  the  upper  portion  of  the  false  mem- 
brane.”— ( Eberle .) 

Causes. — The  cold,  damp,  variable  weather,  common 
in  autumn  or  spring,  is  considered  as  the  most  frequent 
cause  of  croup,  which  may  also  be  favored  in  its  effect 
by  the  fashion  of  leaving  the  neck  and  upper  portion 
of  the  chest  perfectly  bare;  however,  if  children  are 
accustomed  to  going  dressed  in  this  manner,  and  other- 
wise lightly  clad,  if  the  weather  is  mild,  perhaps  this 
does  not  exercise  so  much  influence  in  producing  the 
disease,  as  has  been  imagined.  The  system  seems  to 
be  more  liable  to  be  attacked  with  croup,  from  the  in- 
fluence of  cold,  during  convalescence  from  measles, 
scarlet  fever,  &c.  It  also  appears  that  this  disease  is 
more  frequent  during  the  prevalence  of  these  diseases, 
and  also  during  that  of  whooping-cough  ( Pertussis ). 
The  children  of  some  families  are  much  more  liable  to 
the  disease  than  others.  Robust,  very  fat  children  are 
generally  more  liable  to  it,  though  it  is  by  no  means 
confined  to  them.  Children  over  eight  months  old, 
and  under  five  or  six  years,  are  more  liable  to  be  at- 
tacked with  croup,  though  younger  infants,  or  older 
children,  or  even  adults,  may  be,  but  this  is  rarely 
the  case.  Children  that  have  once  had  the  disease,  are 
more  liable  to  be  attacked  again  and  again. 

According  to  the  author’s  observation,  nervous  or  spas- 


CROUP— TREATMENT. 


389 


modic  croup  is  much  more  common  in  low  or  swampy, 
or  what  is  generally  regarded  as  malarious  regions  of 
country,  where  intermittents  and  typhoid  pneumonia  pre- 
vail ; and,  as  before  remarked,  cases  of  this  kind  are  more 
especially  apt  to  make  their  appearance  in  the  early  part 
of  the  night.  It  is,  however,  said  to  be  of  frequent  oc- 
currence elsewhere. 

Treatment. — -In  the  first  variety  of  croup,  noticed 
above,  the  chief  indications,  are,  to  subdue  the  local  in- 
flammation, the  febrile  condition,  and  to  procure  the  dis- 
charge of  the  copious,  viscid,  coagulable,  semi-transpa- 
rent, and  sometimes  frothy  mucus,  which  collects  in  the 
air  passages,  and  which  renders  respiration  more  and 
more  difficult  as  it  accumulates,  or  lodges  in  the  upper 
portion  of  the  windpipe,  and  which,  if  not  removed,  may 
produce  death  by  suffocation,  by  preventing  the  ingress 
of  air  into  the  lungs. 

When  the  attack  is  of  the  most  violent  inflammatory 
form,  distinguished  medical  authors  consider  prompt 
and  decisive  general  blood-letting , in  the  early  period 
of  the  disease,  as  being  absolutely  imperative  and  in- 
dispensable ; while,  later  in  the  disease,  it  may  be  of 
doubtful  efficacv,  or  even  detrimental.  The  amount  of 
blood  to  be  drawn  must  depend  on  the  age  and  constitu- 
tion of  the  patient  and  the  violence  of  the  disease,  and 
can  better  be  judged  of  by  the  effect  it  produces;  as,  when 
paleness  of  the  lips  or  face,  fainting,  or  free  perspiration 
occurs,  the  flow  of  blood  should  be  arrested.  It  is  fre- 
quently somewhat  difficult  to  bleed  children,  especially 
those  that  are  fat,  on  account  of  the  deepness  or  obscurity 
of  the  veins.  Fortunately,  however,  if  the  disease  be 
promptly  attacked  in  its  incipient  stages,  with  the  proper 
remedies,  blood-letting  is  rarely  necessary.  If  it  should 
be  practiced,  and  the  symptoms  subsequently  seem  to 


390 


CROUP— TREATMENT. 


demand  a repetition  of  it,  it  will  usually  be  more  advisa- 
ble to  resort  to  local  blood-letting,  by  means  of  leeches 
applied  to  the  throat,  and  the  nauseating  influence  of 
lobelia  inflata,  or  tartar  emetic;  indeed,  if  these  articles, 
or  either  of  them,  is  early  and  promptly  given,  blood- 
letting, in  a large  majority,  if  not  all  cases,  may  be  en- 
tirely dispensed  with.  If  parents  would  early  resort  to 
either  of  these  articles,  the  disease  might  generally  be 
easily  controlled,  but  if  it  is  suffered  to  run  its  course  for 
some  time,  the  best  directed  efforts  of  a physician  may 
be  ineffectual.  I would,  therefore,  insist  that  parents 
lose  no  time  in  promptly  attending  to  the  early  stages  of 
this  affection.  If  a physician  is  convenient,  call  him  in 
immediately ; if  not,  give  an  emetic  of  lobelia  or  tartar 
emetic,*  or  ipecac.,  and  after  free  vomiting  has  been  in- 
duced, give  a dose  of  calomel,  say  from  three  to  six  or 
eight  grains.  The  system  should  now  be  kept  under  the 
slightly  nauseating  influence  of  small  doses  of  lobelia  and 
ipecac.,  or  tartar  emetic  and  ipecac.,  repeated  every  hour, 
or  more  or  less  frequently,  according  to  the  severity  of 
the  disease  and  the  influence  of  these  remedies.  The 
vomiting  causes  a discharge  of  the  viscid,  tough  mucus 
which  accumulates  in  the  air  passages,  especially  about 
the  upper  portion  of  the  windpipe,  and  the  little  patient 
is  now  greatly  relieved  in  every  respect,  the  breathing 
being  more  free  and  easy.  If  the  breathing  should 
again  become  laborious,  a mixture  of  ipecac,  with  lobelia 
or  tartar  emetic,  should  be  given,  so  as  again  to  nauseate 
and  produce  vomiting.  This  course  should  be  resorted 
to  again  and  again,  as  the  tough  mucus,  to  any  consider- 
able extent,  impedes  or  impairs  the  freedom  of  respiration. 

> 

* When  tartar  emetic  is  given  to  young  children,  it  will  he  advisable  to 
add  some  paregoric  to  the  solution,  to  prevent  too  much  griping  and  irri- 
tation of  the  stomach  and  bowels. 


CROUP— TREATMENT. 


391 


After  the  second  or  third  vomiting,  if  necessary  to  resort 
to  it  again,  it  will  generally  be  advisable  to  use  ipecac. 
In  twelve  or  twenty -four  hours,  if  the  disease  is  not  almost 
entirely  removed,  it  may  be  well  to  repeat  the  dose  of 
calomel.  If  the  medicine  should  purge  too  severely,  it 
should  be  moderated  with  a little  paregoric,  from  five  to 
fifteen  drops,  according  to  the  age  of  the  patient,  if  under 
six  years  of  age.  As  to  local  applications,  I do  not  place 
much  reliance  upon  them;  a piece  of  flannel  dipped  in 
spirits  turpentine,  and  applied  to  the  throat  till  it  pro- 
duces a burning  sensation;  or  a snuff  plaster,  applied  to 
the  same  place ; or,  the  application  of  a garlic  or  onion 
poultice  may  afford  some  relief.  As  the  disease  subsides, 
from  five  to  twelve  drops  of  Coxe’s  hive  syrup,  four  or 
six  times  a day,  or  if  this  is  not  at  hand,  small  doses 
(from  half  a grain  to  a grain)  of  ipecac.,  or  the  decoc- 
tion or  infusion  of  boneset,  may  be  given  in  such  quan- 
tities as  to  produce  slight  nausea,  and  a gentle  or  slight 
moisture  of  the  skin,  to  insure  recovery,  and  prevent  a 
return  of  the  disease.  Two  or  three  free  evacuations 
from  the  bowels  should  be  procured  at  the  onset  of  the 
disease,  during  the  period  of  febrile  excitement;  after 
which,  one  or  two  operations  daily  are  usually  sufficient ; 
as  active  purging  at  this  time  would  do  harm,  by  ex- 
hausting the  system. 

After  the  febrile  excitement  has  been  reduced  by  vo- 
miting, and  the  other  means  that  may  have  been  thought 
proper,  and  a remission  brought  about,  I have  found 
quinine  in  free  doses  (from  two  to  five  grains,  according 
to  the  age  of  the  patient),  repeated  three  or  four  times  a 
day,  superior  to  anything  else  in  putting  a check  to  the 
further  progress  of  the  disease;  not  neglecting,  however, 
the  use  of  such  other  articles  as  the  symptoms  may  re- 
quire. My  experience  with  quinine,  in  croup,  has  not 
been  extensive  enough  to  ascertain  to  what  extent  it 


392 


CROUP— TREATMENT. 


may  be  profitably  given,  as  I have  generally  pursued 
the  treatment  recommended  by  authors;  but  from  the 
known  influence  of  quinine,  when  given  in  free  doses, 
in  arresting  inflammation  in  its  incipient  stages,  in 
other  organs,  attended  with  febrile  excitement,  and  from 
analogy,  I am  inclined  to  believe  that  if,  soon  after  free 
vomiting  was  induced,  a good-sized  dose  of  quinine  was 
given,  with  the  dose  of  calomel  that  is  above  recom- 
mended, at  this  time,  it  would  have  a powerful  influence 
in  putting  a stop  to  the  disease.  Opiates  at  this  time 
are  often  of  much  service,  and  are,  perhaps,  too  seldom 
exhibited. 

“ In  the  advanced  periods  of  the  disease,  there  exists 
often  so  much  torpor  or  insensibility  of  the  system,  in 
consequence  of  the  imperfect  decarbonization  of  the  blood 
and  vascular  congestion  in  the  brain,  that  great  difficulty 
is  experienced  in  procuring  the  operation  of  emetics.  To 
obviate  this  gastric  insensibility,  and  procure  emesis,  we 
must  endeavor  to  diminish  the  sanguineous  congestion 
in  the  head;  and  this  may,  in  general,  be  readily  accom- 
plished,” except  when  near  the  fatal  termination,  “ by 
putting  the  patient’s  feet  in  warm  water,  and  applying  a 
napkin,  wet  with  very  cold  w’ater,  to  the  head.  The 
abstraction  of  blood,  too,  wrhile  the  patient  is  supported 
in  a sitting  or  erect  posture,  will  rarely  fail  to  insure  the 
operation  of  an  emetic  under  the  circumstances  in  ques- 
tion.” ( Eberle .) 

In  the  early  stages  of  the  disease,  when  the  skin  is 
hot  and  dry,  the  warm  or  tepid  bath  is  recommended  by 
some  authors,  and  it  may  be  of  benefit,  under  these 
circumstances,  but  I do  not  think  that  much  reliance 
should  be  placed  in  it.  Never  having  tried  it,  I would 
not  here  recommend  the  cold  or  shower  bath,  or  the 
pouring  cold  water  over  the  body,  as  is  particularly 
enjoined  in  the  inflammatory  or  second  variety  of  re- 


CROUP— TREATMENT. 


393 


mittent  fever;  but  in  the  early  stage  of  highly  inflam- 
matory croup,  when  the  skin  is  hot  and  dry,  the  face 
flushed,  and  the  pulse  full  and  hard,  I am  inclined  to  be- 
lieve that  the  application  of  cold  water,  in  the  manner 
above  mentioned,  so  as  to  control  the  febrile  excitement, 
and  probably  also  tend  to  relieve  the  local  inflammation, 
would  be  of  much  service.  I think  these  suggestions 
are  worthy  of  being  tested  by  the  profession.  In  this 
form,  tartar  emetic  is  probably  superior  to  any  other 
article.  The  system  should  be  kept  under  its  emetic 
and  nauseating  influence  till  the  excitement  is  subdued, 
and  used  to  a less  extent  subsequently. 

In  the  latter  stage  of  the  disease,  or  after  it  has  lost  its 
acute  inflammatory  character,  if  viscid  accumulations 
clog  the  upper  portion  of  the  windpipe,  and  an  emetic 
is  necessary  to  remove  them,  some  of  the  followdng  arti- 
cles should  be  selected  ; viz.,  ipecacuanha,  boneset,  syrup 
of  squills,  solution  of  common  salt  (in  warm  water),  mus- 
tard, alum,  white  vitriol  ( sulph . zinc),  blue  stone  ( sulph . 
copper).  Some  authors  speak  favorably  of  the  seneka 
snake-root  {poly gala  senega).  The  late  Dr.  Eberle  says, 
“ After  the  complaint  has  been,  in  some  degree,  subdued, 
or  lost  its  acute  inflammatory  character,  its  influence  is 
often  conspicuously  beneficial.  For  the  removal  of  the 
dry  and  hoarse  cough,  and  slight  oppression  of  the  res- 
piration, which,  in  some  instances,  remain  after  the  in- 
flammation has  been  subdued,  we  possess  no  remedy 
equal  in  usefulness  to  the  polygala.  It  is,  moreover,  a 
decidedly  useful  remedy  in  all  instances  of  chronic 
croupy  affections,  and  in  the  catarrhal  and  pectoral  affec- 
tions which  remain  as  the  sequela  of  this  and  other  acute 
affections  of  the  respiratory  organs.  It  is  best  given  in 
decoction.  An  ounce  of  the  root  to  a pint  of  boiling 
water,  suffered  to  simmer  for  fifteen  or  twenty  minutes, 
26 


394 


CROUP-TREATMENT. 


and  afterwards  sweetened  with  honey.  The  dose  of  this 
is  about  an  ounce  (two  tablespoonfuls)  every  hour  or  two, 
according  to  the  urgency  of  the  symptoms.”  In  this 
latter  stage,  perhaps,  puccoon  or  blood-root  would  be 
equally  or  more  efficacious,  and  rendered  more  so,  by 
the  addition  of  a little  sulphate  of  zinc  and  paregoric. 
To  an  infusion  or  tincture  of  the  puccoon,  an  equal  por- 
tion, or  one-third  of  paregoric,  may  be  added,  and  ten 
or  fifteen  drops  given  in  a little  milk,  every  two  or  three 
hours,  till  sufficient  relief  is  obtained ; after  which  a 
dose,  three  or  four  times  a day,  or  less  frequently,  as  the 
disease  subsides,  may  suffice.  If  the  zinc  be  added,  a 
dose  of  the  solution  should  contain  about  one-twelfth 
of  a grain  of  this  article.  After  , the  mixture  is  made, 
it  may  be  sweetened  with  honey  or  sugar. 

Some  authors,  within  the  last  few  years,  maintaining 
that  the  inflammation  generally  commences  about  the 
tonsils  or  fauces,  and  extends  to  the  larynx  and  wind- 
pipe, and,  in  some  cases,  into  the  bronchia,  insist  on  the 
importance  of  the  early  application  of  a strong  solution 
of  lunar  caustic  (from  twelve  to  twrnnty  grains  to  the 
ounce  of  water)  to  the  inflamed  surface  of  the  tonsils, 
palate,  uvula,  .&c.,  so  as  to  arrest  the  disease  in  its  in- 
cipient stages,  before  the  inflammation  extends  into  the 
larynx  and  windpipe.  There  are  but  few,  however, 
except  physicians,  who  have  sufficient  knowledge  to 
apply  this  properly.  It  may  be  done  with  a fine  camel's 
hair  pencil,  or  a small  piece  of  sponge,  tied  to  a stick  or 
whalebone. 

In  those  cases  in  which  a false  membrane  has  formed, 
lining  the  windpipe,  but  little  hopes  are  usually  enter- 
tained of  a favorable  result.  In  rare  instances,  emetics 
may  cause  its  expulsion.  Tracheotomy,  laryngotomy, 
or  cutting  into  the  windpipe  or  larynx,  so  as  to  be  able 


CROUP— TREATMENT. 


395 


to  extract  the  false  membrane,  and  allow  the  child  to 
breathe,  is  an  operation  that  has  been  performed  as  a 
dernier  resort,  but  generally  without  success,  and  there- 
fore considered  of  doubtful  propriety.  If  my  recollection 
serves  me  correctly,  I heard  Professor  J.  M.  Bush,  M.D., 
of  Transylvania  University,  say  that  one  of  his  children 
was  attacked  with  croup,  in  which  the  membranous  for- 
mation took  place.  He  called  in  Professor  B.  W.  Dudley, 
w-ho  opened  the  child’s  mouth,  and,  perceiving  the  upper 
portion  of  the  deciduous  membrane,  immediately  caught 
hold  of  and  extracted  it,  and  the  child  soon  recovered. 

Dr.  Charles  D.  Meigs  reports  a case  of  croup,  in 
which  the  false  membrane  had  formed.  After  other  in- 
effectual means  were  resorted  to,  as  a dernier  resort,  in 
the  advanced  stage  of  the  disease,  tracheotomy  was  per- 
formed by  Dr.  Pancoast,  and  the  child  recovered.  “ After 
laying  bare  the  trachea,  he  divided  the  second,  third,  and 
fourth  cartilaginous  rings ; immediately  upon  opening 
the  trachea,  a discharge  took  place  of  mucus,  mixed  with 
blood  and  portions  of  plastic  lymph.  In  forty  seconds, 
the  child  breathed  with  great  freedom.  The  next  day 
the  child  was  up  and  running  about.”  An  elliptical 
portion  of  cartilage  was  cut  from  the  trachea,  so  as  to  keep 
an  opening  through  i|,  and  the  edges  of  the  soft  parts  were 
kept  apart  by  a leaden  wire — with  hooked  ends — which 
passed  around  the  neck.  For  further  particulars  in  rela- 
tion to  this  case,  see  the  American  Journal  of  the  Medical 
Sciences , Oct.  1848. 

Nervous  or  spasmodic  croup  is  the  most  common  form 
in  the  South,  and  perhaps  also  elsewhere.  It  is  usually 
very  easily  controlled  by  the  exhibition  of  an  emetic, 
of  which  lobelia  is  probably  the  best,  given  alone,  or 
combined  with  ipecac.  Any  of  the  other  emetics  may 
be  used,  the  tartar  emetic,  however,  being  unnecessarily 
violent,  in  most  cases,  unless'  paregoric  be  added  to  the 


396 


CROUP-TREATMENT. 


solution,  and  perhaps  even  then.  Shortly  after  the  ope- 
ration of  an  emetic,  the  exhibition  of  two  grains  of  calo- 
mel, in  many  instances,  may  be  of  service  unless  the 
attack  be  very  slight,  in  which  case  it  may  be  dispensed 
with.  A recurrence  of  the  attack  may  be  prevented  by 
quinine,  in  doses  of  one,  two,  or  three  grains,  two  or 
three  times  a day,  for  a few  days.  This  is  the  form  of 
croup  in  which  the  old  women  procure  relief  by  the  ex- 
hibition of  onion  juice,  and  similar  articles.  The  syrup 
of  puccoon,  zinc,  and  paregoric,  above  mentioned,  three 
times  a day,  would  also  probably  answer  well  to  avert  a 
return  of  it.  If  this  variety  is  caused  by  worms  or  other 
irritating  matters  in  the  stomach  or  bowels,  these  should 
be  removed  by  emetics,  mild  cathartics,  or  anthelmintics 
in  the  case  of  worms.  In  this  latter  condition,  give  first 
two  or  three  grains  of  calomel,  after  the  operation  of  an 
emetic,  as  above  advised  ; and,  after  it  operates  on  the 
bowels,  Jerusalem  oak,  pinkroot,  china  root,  spirit  of 
turpentine,  or  other  worm  medicines  should  be  given. 

In  addition  to  what  has  already  been  said  in  relation  to 
the  application  of  lunar  caustic  to  the  larynx  in  croup,  I 
find  the  following  in  the  January  No.  of  the  American 
Journal  of  the  Medical  Sciences , for  1848. 

“ Croup  cur edhy  cauterizing  the  larynx  with  a solution 
of  the  nitrate  of  silver. — Dr.  Latour  was  sent  for  to  a 
child  of  four  years  old,  ill  of  sore-throat,  accompanied 
with  a hoarse  cough,  fever,  anxiety,  and  other  severe 
symptoms,  the  uvula  and  right  tonsil  being  covered  with 
very  adherent  false  membranes.  Nitrate  of  silver  in  the 
solid  form  was  immediately  applied  to  all  the  afflicted 
parts  within  reach,  and  a vomit  was  given,  by  which 
some  fragments  of  false  membrane  were  brought  away. 
Next  day,  the  false  membrane  had  not  covered  the  left 
tonsil,  but  appeared  to  have  extended  downwards,  and 
the  larynx  seemed  to  be  involved  in  the  disease,  as  there 


CROUP— TREATMENT. 


397 


was  a suppressed  hissing  cough,  and  a loss  of  voice.  Ob- 
jecting, as  insufficient,  to  the  usual  method  of  applying 
the  nitrate  of  silver  in  such  cases,  namely,  by  introduc- 
ing into  the  back  part  of  the  throat  a sponge  dipped  in 
the  solution  of  the  salt,  Dr.  L.  determined  to  use  a 
stronger  solution,  between  seven  and  eight  grains  to  the 
ounce  of  water,  and  to  adopt  a method  of  applying  it 
which  he  had  already  published  in  the  ‘ Clinique  des 
Hopitauz  des  Enfans This  consists  in  saturating  a 
strong  ball  of  lint  in  the  solution,  and  conveying  it  to 
the  opening  of  the  larynx  by  means  of  a long,  curved, 
pair  of  forceps,  and  then  squeezing  out  the  solution  by 
compressing  the  ball  between  the  blades.  In  this  man- 
ner, the  solution  was  applied  in  the  case  referred  to 
every  eight  hours,  for  four  days,  with  complete  success ; 
the  voice  was  first  restored,  and  then  the  convalescence 
soon  became  complete.”* 


* From  Gazette  Medicate  de  Paris,  August  21,  1847. 


APPENDIX. 


4 


GLAP.  (GONORRHOEA.) 

My  object  is  briefly  to  notice  the  subject  of  Clap , 
from  the  fact  of  its  being  so  often  improperly  treated, 
which  renders  it  difficult  to  cure,  sometimes  producing 
stricture,  enlarged  prostate,  affecting  the  bladder,  &c., 
and  also  exercising  a deleterious  influence  on  the  general 
system. 

The  clap  usually  manifests  itself  in  three  or  four  days 
after  an  impure  connection,  but  in  some  cases  it  makes 
its  appearance  much  sooner,  and  in  others,  again,  several 
days  later.  “At  first,  a disagreeable  itching  or  prickling 
sensation  is  felt  in  the  point  of  the  urethra,  passing  a short 
distance  up  from  the  orifice,  which,  on  examination,  will 
be  found  slightly  reddened  and  somewhat  tender.  After 
this  sensation  has  continued  for  ten  or  twelve  hours,  the 
mouth  of  the  urethra  becomes  sensibly  inflamed  and 
swollen,  and  a limpid  or  yellowish  matter  begins  to  ooze 
from  it.  The  stinging  and  itching  increase,  and  the 
emission  of  urine  occasions  a severe  smarting  and  burning: 
pain  in  the  anterior  portion  of  the  urethra.  The  pain, 
now,  extends  more  or  less  speedily  inwards  along  the 
urethra;  the  glans  penis  become  swollen,  dark  red,  and 
tender  to  the  touch,  and  the  discharge  acquires  a yellow- 
greenish  color,  resembling  diluted  pus.  Frequent  and 


400 


APPENDIX. 


very  painful  erections  harass  the  patient,  more  especially 
after  he  has  been  some  time  in  bed ; and  on  passing  water 
the  stream  is  forked,  and  the  pain,  in  some  instances, 
is  exceedingly  smarting.” — ( Eberle .)  At  this  stage  of 
the  disease,  when  the  erections,  or  chordee , are  painful 
and  troublesome,  a small  quantity  of  blood  is  occasion- 
ally mixed  with  the  discharge  from  the  urethra,  '‘and 
the  prepuce  sometimes  becomes  much  inflamed,  tumid, 
and  slightly  excoriated  at  the  edges,  and  in  spots  on  its 
internal  surface.  Many  patients  experience  a constant 
aching  pain  in  the  glands  and  body  of  the  penis,  and  oc- 
casionally one  or  both  testicles  become  tender,  inflamed, 
and  much  swollen,  attended  with  pain  along  the  whole 
course  of  the  spermatic  cord.  Considerable  symptomatic 
fever  always  attends,  when  the  inflammation  becomes 
thus  extended  from  the  urethra  to  the  neighboring'  struc- 
tures.  Not  unfrequently  the  whole  track  of  the  urethra 
becomes  inflamed,  giving  rise  to  harassing  sensations  of 
burning  and  titillation  in  the  neck  of  the  bladder  and 
anus,  and  very  severe  cutting  pains  in  the  perineum  on 
making  water.  The  patient,  under  these  circumstances, 
feels  a continual  urgency  to  make  water,  but  from  the 
great  tenderness  of  the  neck  of  the  bladder  and  urethra, 
only  a few  scalding  drops  are  voided  at  a time.  When 
the  testicles  become  inflamed,  the  gonorrhoeal  discharge 

7 O £5 

is  always  sensibly  diminished,  and  in  many  cases  entirely 
suppressed.  Sometimes  some  of  the  engorged  capillaries 
of  the  mucous  membrane  burst,  and  more  or  less  pure 
blood  passes  off.  After  an  uncertain  period,  these  in- 
flammatory symptoms  begin  to  subside.  The  scalding 
pain  in  making  water  gradually  ceases,  the  erections  be- 
come less  frequent  and  painful,  and  the  gonorrhoeal  mat- 
ter acquires  a greater  consistence,  and  becomes  white  and 
ropy. 

“ The  specific  inflammation  of  gonorrhoea  is  primarily 


APPENDIX. 


401 


seated  in  the  mucous  membrane  of  the  urethra,  a short 
distance  above  its  orifice  in  the  fossa  naoacularis , and 
chiefly  affects  the  lacuna  mucosa  of  Morgagni,  and  their 
excretory  ducts.  From  this  point,  however,  it  often  ex- 
tends higher  up  the  urethra,  to  the  membranous  portion, 
the  veru  montanum,  and  neck  of  the  bladder. 

“ Sometimes  the  gonorrhoeal  matter,  in  the  first  in- 
stance, does  not  penetrate  the  urethra  during  impure  ve- 
nereal connection,  but,  being  applied  to  the  glans  penis, 
it  gives  rise  to  irritation  and  a discharge  of  thin,  purulent 
matter  from  the  sebaceous  glands  situated  around  the 
corona  glandis.” — {Eberle.) 

In  women , gonorrhoea,  in  many  instances,  produces 
but  little  irritation,  pain,  uneasiness,  or  excitement. — 
Eberle  says,  that  “ Women,  affected  with  gonorrhoea, 
generally  experience  a disagreeable  itching  and  titillation, 
about  the  orifice  of  the  vagina,  and  at  the  raphe.  In  se- 
vere cases,  the  labia,  nymphae,  and  clitoris,  become  swol- 
len and  extremely  tender;  and  there  is,  generally,  a 
severe  burning  and  stinging  pain  felt  in  voiding  the 
urine.  In  violent  instances  of  the  disease,  there  is  a 
constant  aching  pain,  experienced  in  the  bladder,  womb, 
groins,  and  back;  and  the  upper  and  inner  surface  of  the 
thighs  often  becomes  inflamed,  excoriated,  or  covered 
with  an  inflamed  pustular  eruption,  from  the  irritation 
occasioned  by  the  gonorrhoeal  discharge.” 

What  is  called  the  inflammatory  stage  of  clap,  usually 
lasts  six  or  eight  days,  or  even  longer,  in  some  cases. 
After  this  period,  the  discharges  from  the  urethra  may 
become  even  more  copious  than  previously,  and  are  of 
the  appearance  of  cream,  to  which,  sometimes,  there  is  a 
greenish  tinge.  Now,  the  discharges  are  commonly  at- 
tended with  little  or  no  pain,  perhaps  a slight  burning 
sensation  at  the  time  of  voiding  urine,  and  for  a short 


402 


APPENDIX. 


time  afterwards;  and  the  disease,  in  many  instances,  as- 
sumes a chronic  character,  usually  called  gleet. 

Treatment. — During  the  inflammatory  stage,  the 
treatment  should  be  antiphlogistic  ; therefore,  as  soon  as 
one  is  attacked  with  clap,  if  be  is  of  a full,  sanguine  tem- 
perament, young  and  vigorous,  he  should  be  immediately 
bled  to  a moderate  extent ; but,  whether  or  not  bleeding  is 
now  resorted  to,  he  should  be  freely  purged,  and  his  sto- 
mach kept  nauseated.  For  these  purposes,  he  may  com- 
mence by  taking  ten  grains  of  calomel  with  ten  grains  of 
jalap,  or  twenty  grains  of  rhubarb,  with  the  addition  of  a 
quarter  of  a grain  of  tartar  emetic,  or  a teaspoonful  of  the 
tincture  of  lobelia,  or  two  or  three  grains  of  ipecacuanha. 
These  latter  articles,  for  the  purpose  of  producing  nausea, 
should  be  repeated  every  two  or  three  hours,  and  the 
dose  increased  or  diminished,  according  to  their  effect; 
indeed,  if  the  nausea  wTere  carried  to  the  extent  of 
causing  vomiting  once  a day,  the  disease  would  be  more 
promptly  controlled.  Twenty-four  hours  after  taking 
the  first  dose  of  calomel,  as  above  noticed,  the  bowels 
having  been  freely  purged,  a second  dose  of  six  or  eight 
grains  should  be  given;  after  which,  they  may  be  kept 
loose  by  the  use  of  the  nauseants  above  mentioned ; 
and,  if  necessary,  the  additional  use  of  cream  of  tartar. 
This  may  be  dissolved  in  a mucilaginous  solution,  as  of 
gum  Arabic,  flaxseed,  slippery  elm,  benne,  &c.,  and 
drunk  occasionally  or  frequently  through  the  day,  so  as 
to  keep  the  bowels  open;  or  a dose  of  two  or  three  tea- 
spoonfuls or  more  may  be  taken  at  once,  dissolved,  as 
above  mentioned;  or  it  may  be  dissolved  in  warm  water, 
and,  if  desired,  sweetened.  Other  cathartics  may  be  se- 
lected and  used  instead  of  this.  This  treatment  should 
be  persevered  in  till  the  inflammatory  stage  of  the  dis- 
ease has  subsided. 


APPENDIX. 


403 


As  to  local  treatment,  in  the  mean  time,  Professor  B. 
W.  Dudley,  M.  D.,  recommends  the  frequent  application 
of  warm  water,  which  may  be  done  by  sitting  in  or  over 
the  vessel  containing  it,  and  frequently  throwing  the 
water  upon  the  genitals.  For  the  relief  of  the  painful 
erections  at  night,  the  wrnrm  w7ater  may  occasionally  be 
applied ; or  a soft  opiate  poultice  may  procure  some  re- 
lief; as  of  Jimpson-weed  leaves,  nightshade,  opium; 
or  an  ointment  of  morphine,  or  camphor  and  mercurial 
ointment.  The  parts  should  be  kept  clean,  by  washing 
them  three  or  four  times  a day  in  weak  tepid  soap-suds. 
A clean  piece  of  cotton  cloth  should  be  worn  over  the 
genitals,  which  ought  to  be  changed  for  another  twice  or 
thrice  a day,  or  as  often  as  it  becomes  soiled  with  the  go- 
norrhoeal discharges. 

During  the  first  six  or  eight  days,  or  the  inflammatory 
stage,  the  affected  individual  should  live  very  abste- 
miously, as  upon  small  quantities  of  gruel,  weak  soup, 
panada,  rice  soup,  and  the  like.  Stimulants  of  all  kinds 
should  be  eschewed.  The  individual  should  also  avoid 
exercise,  keep  quiet,  and  remain  mostly  in  a horizontal 
position,  as  upon  a bed,  sofa,  &c. 

Unfortunately  during  this  stage  it  is  too  common,  both 
amongst  those  afflicted  with  the  disease  and  physicians, 
to  give  balsam  copaiva  and  other  stimulating  diuretics, 
and  also  to  throw  stimulating  astringent  injections  into 
the  urethra,  often  thus  making  the  disease  worse — more 
painful,  distressing,  protracted,  difficult  to  cure — and  also 
sometimes  producing  swelling  of  one  or  both  testicles, 
stricture,  &c. 

After  the  acute  or  inflammatory  stage  has  passed  off, 
balsam  copaiva,  cubebs  or  turpentine,  should  be  freely 
given  three  times  a day  in  mucilaginous  solution,  or 
mixed  with  sugar.  The  following  formula  will  answer 
a good  purpose  at  this  time  : — • 


404 


APPENDIX. 


R . Balsam  copaiva  two  flmdounces ; 

Sulphate  of  zinc  half  a drachm  ; 

Gum  Arabic,  pulverized,  a tahlespoonful ; 

W ater  four  fluidounces. 

Dissolve  the  zinc  in  the  water,  add  the  gum  Arabic,  and 
then  the  balsam  copaiva,  and  shake  it  well  just  before 
using  it.  Dose,  from  a dessertspoonful  to  a tablespoon ful 
three  times  a day.  If  it  should  operate  too  much  on  the 
bowels,  half  an  ounce  of  laudanum  should  be  added  to 
the  mixture.  It  may  be  taken  alone  or  mixed  with  sugar ; 
or,  if  it  is  not  convenient  to  prepare  the  above,  from 
forty  to  sixty  drops,  or  near  a teaspoonful  of  the  balsam 
copaiva,  may  be  mixed  with  sugar,  and  thus  taken.  Dr. 
Eberle  says  the  following  is  an  excellent  formula  for 
administering  this  article: — 

R.  Balsam  copaiva  one  ounce ; 

Sweet  spirit  of  nitre  half  an  ounce  ; 

Laudanum,  and  spirit  of  camphor,  of  each,  one  drachm. 

Mix.  Of  this,  a teaspoonful  should  be  taken  four  times 
daily. 

When  the  disease  assumes  a chronic  or  gleety  cha- 
racter, spirit  of  turpentine,  or  cubebs,  should  be  mixed 
with  the  balsam  copaiva,  in  the  proportion  of  equal 
quantities  of  the  former,  or  tincture  of  cubebs,  and  the 
balsam ; or,  the  first  two  may  be  mixed  together  in 
equal  quantities,  and  given  in  teaspoonful  doses,  three 
or  four  times  a day,  mixed  with  a little  sugar.  In 
cases  of  this  kind,  I am  inclined  to  think  favorably 
of  the  addition  of  tincture  of  puccoon  root  and  a solu- 
tion of  sulphate  of  zinc  to  the  mixture  of  balsam  and 
turpentine. 

The  use  of  the  above  means  should  be  continued  till 
the  discharge  ceases ; after  which,  the  doses  should  be 
gradually  diminished  for  six,  eight,  or  ten  days;  when, 
if  there  is  no  appearance  of  the  gonorrhoeal  discharge, 
the  individual  may  consider  himself  cured,  though  he 


APPENDIX. 


405 


should  live  temperately,  avoiding  too  much  exercise  or 
excessive  venereal  indulgence,  for  fear  that  the  disease 
might  again  be  developed ; and  this  is  the  more  imper- 
ative, if  the  individual  has  had  it  before. 

If  the  clap  is  disposed  to  yield  to  the  above  means, 
no  injections  into  the  urethra,  of  any  kind,  should  be 
used  ; but,  if  it  is  rather  obstinate,  a silver  bougie  should 
be  smeared  with  balsam  copaiva,  and  introduced  three 
times  a day ; or,  in  obstinate  cases,  twenty  grains  of 
lunar  caustic,  pulverized  finely,  and  rubbed  up,  or  in- 
timately mixed  with  half  an  ounce  of  lard,  or  citrine 
ointment,  smeared  on  the  bougie,  may  be  used  in  the 
same  manner.  Weak  solutions  of  sulphate  of  zinc,  lunar 
caustic,  sugar  of  lead,  oil  of  vitriol,  or  sulphate  of  cop- 
per, may  be  injected  into  the  urethra,  instead  of  the 
above;  but  care  is  requisite  that  they  be  of  the  proper 
strength,  and  carefully  injected,  so  that  the  solution  may 
come  in  contact  with  the  diseased  surface,  and  that  the 
end  of  the  syringe  do  not  touch  the  diseased  urethra  so 
as  to  excite  increased  irritation  and  inflammation.  The 
following  is  the  proportion  in  which  these  articles  may 
be  added  to  an  ounce  of  water,  using  the  weaker  solutions 
first;  as  the  disease  becomes  more  protracted,  or  chronic, 
the  strength  should  be  increased ; sulphate  of  zinc , from 
a grain  and  a half  to  eight  grains ; lunar  caustic,  from 
one  to  six  grains ; sugar  of  lead,  from  three  to  eight 
grains;  oil  of  vitriol,  a drop  to  a drop  and  a half;  sul- 
phate of  copper,  from  one  to  four  grains. 

Dr.  Eberle  very  correctly  observes  “that,  where  there 
is  much  irritability  or  active  inflammation  of  the  urethra 
present,  all  astringent  or  irritating  injections  are  highly 
improper.  When  used  under  circumstances  of  this  kind, 
they  are  apt  to  give  rise  to  various  distressing  affections, 
particularly  to  obstinate  chordee,  inflammation  of  the 
body  of  the  penis,  of  the  neck  of  the  bladder,  and  of  the 


406 


APPENDIX. 


testes,  and  to  strictures  in  the  urethra.”  It  should  also 
be  borne  in  mind  that  these  secondary  results  may  take 
place  in  cases  in  which  no  injections  have  been  used,  if 
the  proper  treatment  has  been  neglected. 

The  bowels  should  be  kept  gently  open  by  aperients, 
of  which  blue  mass  or  calomel  should  constitute  a part, 
if  any  of  the  secondary  conditions  above  mentioned 
exist.  Minute  doses  of  corrosive  sublimate,  with  ex- 
tract of  cicuta,  are  favorably  spoken  of  by  some  authors. 
When  one  or  both  testicles  are  swelled  and  painful,  an 
emetic  should  be  given,  and  the  testes  enveloped  in  a 
piaster  made  of  mercurial  ointment  and  camphor.  In 
cases  of  enlarged  prostate,  iodine  and  mercurial  ointments 
should  alternately  be  rubbed  over  it  twice  a day. 

The  general  treatment  recommended  above  is  also  ap- 
plicable to  females,  though  in  them  it  usually  need  not 
be  quite  so  active.  During  the  inflammatory  stage,  the 
parts  should  be  frequently  bathed  or  sponged  with  tepid 
water,  and  also  kept  clean  by  injecting  weak  soap-suds 
into  the  vagina  three  or  four  times  a day,  after  which  a 
weak  solution  of  sugar  of  lead  may  be  thrown  into  it. 

After  the  acute  stage  has  passed  by,  any  of  the  afore- 
mentioned injections  recommended  for  the  male  are  pro- 
per, and  should  be  repeated  three  or  four  times  a day. 
If  the  disease  extends  into  the  urethra,  a silver  bougie 
should  be  smeared  with  balsam  copaiva,  or  some  of  the 
articles  mentioned  heretofore,  and  introduced  into  it  twice 
or  thrice  a day. 

In  chronic  cases,  muriated  tincture  of  iron,  or  iodine, 
is  sometimes  of  much  service.  The  diet  should  be  light, 
in  the  early  stages  of  this  form,  but,  subsequently,  it  may 
be  more  nourishing,  especially  if  there  is  much  debility; 
in  w hich  case  tonics  may  be  necessary. 


APPENDIX. 


407 


II. 

MISCELLANEOUS. 

It  has  been,  and  still  is  too  common  an  error  with 
many,  so  soon  as  an  individual  receives  a severe  concus- 
sion or  jar— as  by  a fall  from  a height,  or  other  severe 
injury,  to  bleed  him  immediately , while  the  pulse  is  very 
small  or  scarcely  perceptible ; the  face  pale,  and  perhaps 
the  extremities  cold. 

In  cases  of  this  kind,  and  during  this  condition,  stimu- 
lants should  be  given,  if  necessary  ; spirits  of  camphor, 
hartshorn,  or  ether,  held  to  the  nose  ; cold  water  sprinkled 
on  the  face  frequently,  and  the  extremities  assiduously 
rubbed  with  the  hands. 

After  reaction  is  fully  established,  the  pulse  being 
hard  and  full ; the  general  surface  and  extremities  warm 
and  dry,  or  even  hot;  perhaps  pain  in  the  head;  it  may 
then  be  necessary  to  take  away  a moderate  quantity  of 
blood,  administer  a mild  cathartic,  and,  if  there  is  much 
pain  in  the  head,  it  should  be  kept  cool  by  the  applica- 
tion of  cold  water.  If  the  reaction  is  moderate,  bleeding 
will  be  unnecessary  ; but  the  bowels  should  be  operated 
on  by  a cathartic,  as  castor  oil,  Epsom  salts,  cream  of 
tartar,  extract  of  butternut,  calomel  and  jalap,  &c. 

If  the  person  thus  injured  should  again  relapse,  stimu- 
lants should  again  be  given;  and,  if  the  case  should  be 
protracted,  quinine  and  other  tonics  may  be  necessary. 
If  any  degree  of  febrile  reaction  attends,  the  occasional 
use  of  the  above  cathartics,  with  the  use  also  of  lemon- 
ade, will  probably  be  demanded. 


408 


APPENDIX. 


III. 

INCISED  WOUNDS. 

Incised  Wounds  are  those  made  by  sharp-edged  in- 
struments; such,  for  instance,  as  an  axe,  drawing-knife, 
pocket-knife,  cutlass,  &c.  It  is  so  common  an  error 
amongst  the  people  generally  to  treat  injuries  of  this 
kind  by  filling  the  wound  with  ashes,  sugar,  soot,  or 
other  improper  materials,  that  I wish  to  call  their  atten- 
tion to  the  proper  treatment  of  wounds  of  this  sort. 

As  soon  as  possible  after  the  occurrence  of  an  incised 
wound,  its  edges  should  be  drawn  together  and  held 
in  this  position,  in  order  that  the  parts  may  soon  unite 
again,  by  what  is  commonly  called  “ healing  by  the 
first  intention ,”  and  mithout  suppurating  or  mattering. 
Before  drawing  the  edges  of  the  wound  together,  howT- 
ever,  if  there  is  any  dirt,  clotted  blood,  or  other  foreign 
matter  in  it,  it  should  be  removed.  The  edges  may 
be  held  in  apposition  by  adhesive  plaster  spread  on 
linen,  by  an  ethereal  solution  of  gun-cotton,  or  by 
stitching  them  together;  or,  on  certain  parts,  the  appli- 
cation of  a bandage  may  suffice  for  this  purpose.  If 
the  plaster,  or  linen  saturated  with  an  ethereal  solution 
of  gun-cotton  be  used,  the  width  of  the  strips  should 
depend  on  the  size  of  the  wound,  as  from  a quarter  of  an 
inch  to  an  inch  wide,  and  sufficiently  long  to  extend 
some  distance  beyond  the  wound,  so  that  it  may  have 
enough  surface  of  skin  to  adhere  firmly  to.  If  the 
wound  is  in  very  fleshy  or  soft  parts,  and  so  large  that 
its  edges  cannot  be  held  in  apposition  by  these  means, 


APPENDIX. 


409 


the  suture  should  be  resorted  to ; and,  in  the  spaces  be- 
tween- the  stitches,  the  adhesive  strips  (either  of  the 
plaster  or  solution  of  gun  cotton),  should  be  applied. 

After  the  wound  has  been  treated  as  above,  if  it  is  dis- 
posed to  bleed  too  much,  some  clean  wool,  dipped  in  a 
mixture  of  flour  and  water,  should  be  applied  to  it.  If 
it  is  on  any  of  the  limbs  where  a bandage  can  be  pro- 
perly applied,  the  bleeding  may  be  arrested  by  it,  taking 
care  to  commence  wrapping  the  limb  at  its  extremity, 
and  firmly  and  smoothly  encircling  it  to  a few  inches 
above  the  wound.  The  bandage  should  be  two  or  three 
inches  wide;  and  it  may  be  profitably  applied  to  wounds 
which  do  not  bleed  too  much,  especially  those  inflicted 
on  the  limbs  or  about  the  head,  or  anywhere  else  where 
it  can  be  used  so  as  to  compress  and  firmly  hold  the 
edges  of  them  together. 

After  a wound  has  been  dressed  as  above,  usually  but 
little  else  is  necessary  than  to  cover  the  parts  with  a soft 
piece  of  folded  cloth.  No  ashes  or  sugar  should  be 
thrown  into  it  to  prevent  it  from  healing,  or  force  it  to 
fill  up  by  granulation,  which  would,  probably,  require 
weeks  or  months.  Let  some  blood  remain  on  its  edges, 
which  serves  to  assist  in  holding  the  parts  together,  and 
to  heal  it. 

If  the  wound  is  large,  and  the  parts  become  consider- 
ably inflamed,  hot,  and  painful,  they  should  be  frequently 
sponged  with  tepid  or  cold  water,  or  water  and  vinegar ; 
or  a cool  poultice,  as  of  slippery  elm,  should  be  applied 
over  the  inflamed  parts,  and  renewed  as  soon  as  it  be- 
comes dry. 

Lacerated , or  contused  wounds  should  be  treated  like 
the  above ; in  the  latter,  as  the  parts  are  not  separated 
or  torn  asunder,  the  application  of  the  bandage,  and  some 
opodeldoc,  will,  perhaps,  be  sufficient.  If  much  inflam- 
27 


410 


APPENDIX. 


mation  should  ensue,  attended  with  considerable  heat 
and  pain,  a cool  poultice  of  slippery  elm,  or  the  frequent 
application  of  tepid  water,  or  of  cool  water  and  vinegar, 
if  it  is  found  to  afford  more  relief,  should  be  used. 

As  the  recent  discovery  of  “ gun  cotton ,”  and  its  adhe- 
sive properties  when  dissolved  in  sulphuric  ether — the 
solution  being  called  “ Collodion1 ’ — have  attracted  much 
attention,  formulas  for  making  these  articles,  and  the  uses 
of  the  latter,  may  be  of  interest  to  the  reader. 

Receipt  for  making  Gun  Cotton. 

Take  about  equal  quantities  of  pure  sulphuric  and 
nitric  acids,  put  them  into  a glass  vessel  (a  glass  tumbler, 
for  instance),  and  put  in  as  much  clean  cotton  or  cotton 
rags  as  the  acids  will  completely  saturate ; let  it  thus  re- 
main for  from  three  to  four  hours,  then  wash  the  cotton 
well  with  water,  and  dry  it  in  the  sun.  Gun  cotton  is 
possessed  of  great  explosive  properties,  and  may  be  used, 
as  a substitute  for  gunpowder. 

“ Collodion ,”  or  Ethereal  Solution  of  Gun  Cotton , or 
prepared  Cotton. 

R.  Gun  cotton  ten  to  twelve  grains ; 

Commercial  sulphuric  ether  one  ounce.  Mix. 

Mr.  S.  Hutchings,  of  Montgomery,  Alabama,  has  pre- 
pared an  ethereal  solution  of  prepared  cotton , which  he 
considers  superior  to  the  Boston  preparation.  His  for- 
mula is  as  follows  : — 

R.  Sulphuric  acid  (commercial)  four  ounces; 

Nitric  acid  (Farr’s  chemically  pure)  two  ounces  : 

Gotton  three  drachms. 

Mix  the  acids.  Saturate  the  cotton  in  the  mixture  for 
six  minutes;  then  gently  press  off  the  acids.  Allow  the 


APPENDIX. 


411 


cotton  to  remain  for  an  hour  in  the  fumes,  in  a covered 
vessel;  then  wash  repeatedly  in  water,  so  as  to  remove 
the  slightest  taste  of  acid,  and  dry  thoroughly  in  the  sun. 
Then, 

To  make  Collodion , 

Take  of  the  prepared  cotton  ten  to  twelve  grains  ; 

Commercial  sulphuric  ether  one  ounce.  Mix. 

The  cotton  should  be  dissolved  in  the  ether  as  soon  as 
it  is  perfectly  dry ; if  kept  for  any  length  of  time  (for 
instance,  a week)  it  loses  to  some  extent  its  solubility, 
which  may  be  owing  to  its  absorption  of  moisture  from 
the  atmosphere. 

The  above  is  a most  excellent  application  to  all  in- 
cised, or  lacerated  wounds.  It  adheres  with  great  te- 
nacity, holds  their  edges  together,  and  gives  them  an 
opportunity  to  heal  by  the  first  intention.  In  the  lan- 
guage of  J.  Marion  Sims,  M.  D.,  of  Montgomery,  Ala- 
bama, “ In  the  application  of  the  solution  to  common 
incised  mounds , nothing  more  is  necessary  than  to  bring 
their  edges  into  apposition,  and  smear  the  wound  over 
with  it,  by  means  of  a camel’s  hair  pencil.  But  in 
wounds  of  greater  magnitude,  requiring  sutures  or  straps, 
it  will  be  necessary  to  use  strips  of  linen  or  cotton  fabric, 
of  the  requisite  length  and  breadth,  well  moistened  with 
the  liquid.  For  this  purpose,  let  one  end  of  the  strip  be 
stuffed  into  the  vial  containing  the  preparation.  When 
thoroughly  saturated,  let  it  be  applied,  and  wait  patiently' 
till  it  becomes  perfectly  dry,  which  will  be  in  from  a half 
minute  to  three,  four,  or  five,  according  to  circumstances. 
The  other  end  of  the  strip  may  now  be  wet  and  applied 
in  like  manner.  In  some  wounds,  as,  for  instance,  after 
amputation,  the  whole  strip  may  be  saturated  at  once  and 
applied  over  the  parts.  Be  sure  of  one  thing,  not  to  feel 
afraid  of  wasting  the  article;  and  of  another,  not  to  be 


412 


APPENDIX. 


in  a hurry;  for  a failure  sometimes  arises  from  using  the 
solution  too  sparingly,  and  again,  from  not  waiting  till  it 
gets  thoroughly  dry.”* 

M.  Mialhe  makes  collodion  in  the  following  manner 

R.  Finely  powdered  nitrate  of  potash  forty  parts  by  weight ; 

Concentrated  or  common  sulphuric  acid  sixty  “ “ “ 

Carded  cotton  two  “ “ “ 

“ Mix  the  nitre  with  the  sulphuric  acid  in  a porcelain 
vessel,  then  add  the  cotton,  and  agitate  the  mass  for  three 
minutes  by  the  aid  of  twTo  glass  rods.”  If  the  sulphuric 
acid  is  weak,  a longer  immersion  of  the  cotton  is  neces- 
sary. “Wash  the  cotton,  without  first  pressing  it,  in  a 
large  quantity  of  water,  and,  when  all  acidity  is  removed 
(indicated  by  litmus  paper),  press  it  firmly  in  a cloth. 
Pull  it  out  into  a loose  mass,  and  dry  it  in  a stove  at  a 
moderate  heat. 

“ The  compound  thus  obtained  is  not  pure  fulminating 
cotton ; it  always  retains  a small  quantity  of  sulphuric 
acid,  is  less  inflammable  than  gun  cotton,  and  it  leaves  a 
carbonaceous  residue  after  explosion.  It  has,  however, 
in  a remarkable  degree,  the  property  of  solubility  in  ether, 
especially  when  mixed  with  a little  alcohol,  and  it  forms 
therewith  a very  adhesive  solution.” 

R . Prepared  cotton  eight  parts  by  weight ; 

Rectified  sulphuric  ether  one  hundred  and  twenty-fire  do. 

Rectified  alcohol  eight  do. 

“ Put  the  cotton  with  the  ether  into  a wrell-stopped 
bottle,  and  shake  the  mixture  for  some  minutes.  Then 
add  the  alcohol  by  degrees,  and  continue  to  shake  until 
the  wdiole  of  the  liquid  acquires  a syrupy  consistency. 
It  may  be  then  passed  through  a cloth,  the  residue 
strongly  pressed,  and  the  liquid  kept  in  a well-secured 
bottle.” — [Med.  News,  Dec.  1848.) 


*New  Orleans  Medical  and  Surgical  Journal,  Sept,  1S48, 


APPENDIX. 


413 


IV. 

WORMS  IN  THE  ALIMENTARY  CANAL. 

The  most  common  symptoms  of  worms  are  generally 
pretty  well  understood;  as  a pallid  or  sallow  complexion, 
with  usually  a fullness  or  protuberance  of  the  abdomen, 
swelling  of  the  upper  lip,  scratching  of  the  nose  and  anus, 
grinding  of  the  teeth,  and  sometimes  sudden  jumps  or 
starts  when  the  child  is  asleep,  sometimes  disagreeable  or 
gnawing  sensations  in  the  belly,  irregularity  of  the 
bowels,  indigestion,  fetid  breath,  more  or  less  debility, 
and  commonly  anaemia;  in  some  cases  fever  is  produced 
{worm  fever),  or  convulsions  or  other  nervous  affections 
occur;  the  appetite  is  generally  variable.  Worms  are 
most  common  in  children  between  the  periods  of  weaning 
and  puberty.  A debilitated  condition  of  the  system 
favors  their  production,  either  in  children  or  adults. 

Treatment.— -At  the  commencement,  if  there  should 
be  attendant  fever,  or  a somewhat  full,  florid  appear- 
ance, one  or  two  doses  of  calomel  (from  two  to  six  or 
eight  grains,  according  to  the  age  and  condition  of  the 
patient)  should  be  given,  with  an  interval  of  twelve  or 
twenty-four  hours,  if  more  than  one  dose  is  taken. 
After  this,  some  of  the  other  anthelmintics  should  be 
administered ; or,  if  the  conditions  mentioned  above 
should  not  be  present  at  first,  calomel  need  not  be 
given,  and  these  at  once  commenced  with.  The  most 
common  worm  medicines  are  spt.  turpentine , norm-seed , 
or  Jerusalem  oak,  pinkroot,  the  bark  of  the  root  of  the 
China-tree , the  hark  of  the  pomegranate  root,  male  fern , 


414 


APPENDIX. 


walnut  rind , wormwood , garlic , tansy , rue,  cowage , pow- 
der of  tin  or  zinc,  copperas , common  salt,  bitters,  &c. 
The  size  of  a dose  of  any  of  these  articles  will,  of  course, 
depend  on  the  age  and  condition  of  the  patient,  and 
should  usually  be  repeated  two  or  three  times  a day. 

For  a child  some  five  or  seven  years  of  age,  the  follow- 
ing answers  very  well 

R . Spt.  turpentine  three  teaspoonfuls  ; 

Sweet  oil  or  castor  oil  three  tablespoonfuls. 

Mix,  and  shake  well  just  before  using;  dose,  a teaspoon- 
ful, taken  alone,  or  mixed  wdth  sugar  or  mucilage  of  some 
kind,  two  or  three  times  a day.  When  the  subject  is 
older  or  younger,  the  dose  should  be  increased  or  di- 
minished accordingly.  The  addition  of  some  twenty 
grains  of  calomel  to  this  mixture  may  add  to  its  anthel- 
mintic virtues;  when  the  calomel  is  added,  its  use 
should  not  be  continued  longer  than  two  or  three  days; 
but,  if  necessary,  it  may  be  resumed  at  a subsequent 
period. 

Usually,  after  giving  some  of  the  anthelmintics  which 
do  not  purge  for  a day  or  two,  it  will  be  advisable,  if 
worms  are  not  discharged,  to  give  a cathartic.  The  ve- 
getable anthelmintics  noticed  above  (except  the  cowage, 
which  should  be  taken  in  syrup),  may  be  given  in  de- 
coction or  infusion,  or  otherwise.  The  seeds  of  the  Je- 
rusalem oak  are  frequently  given  in  sweet  milk.  When 
children  are  wormy,  a very  convenient  way  to  remove 
these  parasites  is  to  incorporate  the  seeds  of  the  Jerusa- 
lem oak  with  candy.  This  may  be  easily  done,  when 
candy  is  made  of  molasses  or  sugar,  in  the  usual  way ; 
just  before  the  syrup  becomes  cool  and  hard,  freely  stir 
in  the  seeds  ; and  when  the  candy  is  prepared,  the  chil- 
dren should  be  allowed  to  use  it  somewhat  freely,  which 
they  will  probably  most  commonly  willingly  and  cheer- 


APPENDIX. 


415 


fully  do.  The  other  anthelmintics  may  be  finely  pul- 
verized, and  given  in  the  same  way. 

The  thread-worm  ( ascarides ) commonly  inhabits  the 
rectum  ; and  for  their  removal,  besides  the  means  men- 
tioned above,  injections  should  be  resorted  to  daily, 
of  solutions  of  common  salt,  or  spirit  of  turpentine  and 
sweet  oil  or  castor  oil,  or  some  bitter  decoction;  as 
of  wormwood,  aloes,  rue,  &c.,  sufficiently  diluted  with 
water. 

In  cases  of  tape-worm,  occurring  in  adults,  large  doses 
of  spirit  of  turpentine  are  highly  spoken  of  by  authors. 
It  may  be  given  in  doses  of  from  one  to  two  or  three 
teaspoonfuls,  with  a tablespoonful  of  castor  oil,  and  some 
sugar  or  thick  solution  of  gum  Arabic,  slippery  elm,  flour, 
or  the  like,  and  taken  once  or  twice  a day.  For  further 
particulars,  see  works  which  treat  more  at  length  on 
this  subject. 

As  there  is  generally  greater  or  less  debility  after  the 
worms  have  been  removed,  or  even  during  their  removal, 
tonics  are  necessary ; and  as,  in  a large  majority  of  cases, 
there  is  a greater  or  less  degree  of  anemia — the  subject 
presenting  a pallid  appearance,  some  of  the  preparations 
of  iron  are  indicated,  which  also  act  well  as  tonics.  For 
this  purpose,  for  children  some  five  or  six  years  of  age 
(and  for  younger  or  older  in  proportion),  a grain  of  cop- 
peras, or  three  or  four  grains  of  carbonate  of  iron,  should 
be  given  in  syrup  or  molasses,  two  or  three  times  a day, 
till  the  health  of  the  patient  is  restored.  Some  of  the 
vegetable  bitters  may  also  be  used;  as  dogwood,  poplar, 
gentian,  quassia,  &c.  Generous  diet,  fresh  air,  and  other 
hygienic  measures  should  be  attended  to. 

The  worms  that  are  generally  met  with  in  the  ali- 
mentary canal,  are  the  round-worm  ( Ascaris  lumbri- 
coides ),  thread-worm  ( Ascaris  vermicularis ),  long  thread- 
worm ( Tricocephalus  dispar ),  long  tape-worm  ( Tcenia 
solium ),  broad  tape-worm  [Tcenia  lata). 


416 


APPENDIX. 


y. 

CATARRH,  OR  A COLD:  COMMONLY  CALLED  “A  BAD 

COLD.” 

As  the  real  nature  of  this  affection  is  so  little  under- 
stood bj  most  persons,  though  it  is  of  common  occur- 
rence, and  as  it  is  often  so  variously  and  improperly 
treated  by  them,  a brief  notice  of  it  here  may  not  be 
without  profit  to  many.  It  should  be  borne  in  mind 
that,  though  it  is  produced  in  cold  and  wet  or  variable 
weather,  or  by  sudden  exposure  to  a cool  current  of 
air,  after  being  in  a crowded  ball-room  or  other  warm 
place,  the  pathological  condition  is  a superficial  inflam- 
mation of  a greater  or  less  portion  of  the  mucous  mem- 
brane, or  mucous  follicles  of  the  air  passages,  more 
particularly  of  the  windpipe,  bronchi,  and  nasal  cavi- 
ties, with,  in  some  cases,  a febrile  condition  of  the 
system. 

The  symptoms  are  cough  and  sneezing,  with  increased 
secretion  of  mucus  from  the  air  passages;  a feeling  of 
lassitude  or  dullness;  probably  watery  eyes,  a greater  or 
less  degree  of  fever  and  thirst,  and  commonly  a fullness 
of  the  head,  which  is  said  by  the  patient  to  be  “ stopped 
up.” 

In  some  severe  attacks,  that  are  neglected  or  impro- 
perly treated,  it  becomes  chronic  and  troublesome;  and, 
it  has  been  said,  may  run  into  consumption. 

Treatment. — Bad  colds  are  often  so  slight  as  to  get 
well  without  the  exhibition  of  medicines.  At  the  onset, 
in  violent  attacks  in  young  plethoric  persons,  in  which 


APPENDIX. 


417 


the  febrile  excitement  is  considerable,  with  pain  in  the 
head,  a moderate  quantity  of  blood  may  be  taken  from 
the  arm,  though  this  is  very  rarely  if  ever  necessary,  in 
the  South.  An  emetic  and  cathartic,  or  a few  doses  of 


some  cathartic,  are  usually  sufficient.  I have  generally 
found  a moderate  dose  of  Epsom  salts  (three  or  four  tea- 
spoonsful)  taken  at  bed-time,  for  several  nights  in  suc- 
cession, suffice  to  cure  a cold.  Bathing  the  feet  and  legs 
in  hot  water  for  about  twenty  minutes,  just  before  going 
to  bed,  and  immediately  wiping  them  dry,  may  be  of 
service;  so  also  may  drinking  a little  warm  sage  tea, 
after  getting  in  bed,  so  as  to  favor  slight  perspiration. 

If  the  cough  is  troublesome,  the  following  mixture 

O 1 O 

may  be  of  much  service  : — 


Or, 


EL.  Syrup  of  squills 
Tartar  emetic 
C Ipecacuanha,  or, 

\ Tincture  of  lobelia 
Sulphate  of  morphine 
Water 


two  fluidounees; 
six  grains ; 
two  scruples ; 
one  fluidounee ; 
five  grains ; 
one  fluidounee. 


Dissolve  the  tartar  emetic  and  morphine  in  the  water 
(if  the  water  is  used  instead  of  the  tincture  of  lobelia;  if 
the  latter  is  used,  dissolve  these  ingredients  in  it),  then 
mix  it  with  the  syrup  of  squills,  and  shake  well  before 
using : dose,  a teaspoonful,  three  or  four  times  a day,  so 
as  scarcely  to  nauseate  the  stomach.  If  the  cough  is 
troublesome  at  night,  a dose  should  be  taken  to  allay  it; 
or  if  there  is  little  or  no  febrile  excitement,  a teaspoonful 
or  two  of  paregoric,  or  thirty  or  forty  drops  of  laudanum, 
or  a quarter  or  third  of  a grain  of  morphine,  may  be  used 
for  the  same  purpose.  Five  grains  of  morphine  dissolved 
in  an  ounce  of  tincture  of  lobelia,  and  this  added  to  two 
fluidounees  of  Coxe’s  hive  syrup,  and  the  mixture  shaken 
and  taken  in  doses  of  a teaspoonful  three  or  four  times  a 
day,  may  be  used  instead  of  the  above  formula  or  mix- 


418 


APPENDIX. 


ture.  In  cases  that  are  somewhat  protracted,  the  ad- 
dition of  either  of  the  above  mixtures  to  an  equal  quan- 
tity of  sweet  spirit  of  nitre,  and  taken  in  doses  of  from 
one  to  two  teaspoonfuls,  three  times  a day,  has  appeared 
to  be  of  much  service.  Other  articles,  wThich  common 
sense  may  suggest,  guided  by  the  nature  of  the  disease, 
may  also  be  of  use. 

If  there  is  febrile  excitement,  the  diet  should  be  light 
and  cooling ; otherwise,  little  or  no  alteration  from  the 
usual  mode  of  living  is  necessary. 

If  the  affection  becomes  chronic , the  treatment  for 
chronic  bronchitis  will  be  proper ; to  which  the  reader  is 
referred. 


VI. 

EPHEMERAL  FEVER. 

On  account  of  the  susceptibility  of  young  children  to 
be  morbidly  affected  by  slight  causes,  which  mayor  may 
‘not  be  appreciable,  a febrile  condition  is  sometimes  in- 
duced in  them,  which  may  last  for  several  hours  and  then 
pass  off,  and  it  may  or  may  not  return  the  next  ensuing 
day,  in  mild  cases.  In  severe  cases,  the  fever  will  pro- 
bably last  a much  longer  time,  perhaps  for  ten  or  twelve 
hours  or  more.  In  many  of  these  the  brain  becomes  con- 
siderably affected,  even  to  coma  or  convulsions,  or  jerking 
of  the  limbs.  The  pulse  is  greatly  increased  in  frequency, 
and  to  some  extent  in  fullness  and  hardness.  The  fever 
is  most  likely  to  be  at  its  acme  in  the  afternoon ; and 
will  probably  subside  during  the  night,  especially  if  the 
proper  remedies  have  been  given ; and  it  may  return  again 
the  ensuing  day.  The  fever  is  generally,  if  not  always, 


APPENDIX. 


419 


preceded  by  coldness  of  the  extremities,  which  may  even 
present  a purplish  or  bluish  appearance,  as  in  the  cold 
stage  of  an  intermittent.  When  the  fever  is  at  its  highest 
the  skin  is  hot  and  dry,  and  it  is  at  this  time  that  the  brain 
is  most  affected.  This  disease  is  usually  most  severe, 
according  to  my  observation,  in  florid,  healthy  looking 
children. 

Treatment. — A solution  of  tartar  emetic,  lobelia,  or 
ipecac,  should  be  given,  so  as  to  nauseate  the  stomach  for 
a time,  and  then  produce  free  vomiting.  In  florid,  san- 
guine looking  children,  tartar  emetic  is  superior  to  either 
of  the  other  articles.  After  free  puking  has  been  induced, 
the  system  should  be  kept  under  its  slightly  nauseating 
influence  till  the  fever  is  subdued.  Abput  an  hour  after 
the  vomiting,  two  or  three  grains  of  calomel  should  be 
given,  and  in  severe  cases  it  ought  to  be  repeated  once  or 
twice,  with  intervals  of  twelve  hours.  The  bowels  should 
be  moved  rather  freely  at  the  commencement,  which  the 
tartar  emetic  and  calomel  are  almost  sure  to  do.  During 
the  period  of  high  febrile  excitement,  the  child’s  head 
should  especially  be  kept  cool,  with  cold  water,  in  cases 
in  which  the  brain  is  likely  to  suffer,  and,  indeed,  the 
whole  body  may  be  sponged  with  cool  water,  provided  it 
can  be  done  without  fretting  the  child  much. 

After  the  fever  has  been  subdued,  to  prevent  a return 
of  it,  two  or  three  grains  of  quinine  should  be  given  every 
four  or  five  hours.  The  diet  should  be  light  for  a day  or 
two. 


420 


APPENDIX. 


VII. 

FOR  THE  ITCH.  (SCABIES.) 

Many  articles  have  been  used  for  the  cure  of  the  itch, 
but  perhaps  a mixture  of  pulverized  sulphur,  lard,  and 
soap,  is  about  as  good  as  any.  This  mixture  should  be 
rubbed  on  at  night,  on  going  to  bed,  and  persevered  in 
till  a cure  is  effected.  Red  precipitate  ointment , made  by 
mixing  the  red  precipitate  with  mutton  suet,  is  also  a 
good  remedy,  but  the  sulphur  ointment  is  preferable. 


GLOSSARY 


A. 

Abnormal.  Morbid,  or  a deviation  from  health. 

Acupuncture.  To  puncture  parts  with  a fine  needle. 

Ad  Infinitum.  A Latin  phrase,  which  means — »to  infinity,  or  without  limit. 

Adjuvant.  A medicine  which  assists  another. 

Albumen.  The  white  of  an  egg  consists  almost  entirely  of  albumen.  It  is 
also  one  of  the  ingredients  of  animal  and  vegetable  substances— “is 
found  in  the  serum  of  the  blood,  chyle,  &c. 

Albuminuria.  A morbid  condition  of  the  system,  in  many  cases  attended 
with  disease  of  the  kidneys,  characterized  by  the  presence  of  albumen 
in  the  urine. 

Algide.  Icy  coldness ; applied  to  one  form  of  congestive  chill. 

Alvine.  Pertaining  to  the  bowels  or  abdomen ; alvine  discharges,  means 
the  discharges  from  the  bowels,  as  from  the  operation  of  a cathartic, 
or  in  diarrhoea. 

Amenorrhcea.  Absence  of  the  menses  or  catamenia,  in  females  who  have 
arrived  at  the  age  of  puberty,  and  previous  to  the  proper  time  for 
their  cessation  in  advanced  life. 

Anasarca.  Dropsy  of  the  cellular  membrane,  or  general  dropsy. 

Anemia.  Privation  of  blood  ; the  opposite  of  plethora,  or  hyperaemia. 
Anemic  persons  are  pale  and  enfeebled ; and  there  is  a greater  or 
less  diminution  in  the  ratio  of  the  red  corpuscles  of  the  blood. 

Anemic.  Pertaining  to  anemia. 

Animalcule.  An  extremely  small  animal,  which  may  be  seen  by  means 
of  the  microscope. 

Antiphlogistic.  Opposed  to  inflammation;  generally  applied  to  lowering 
treatment;  as  bleeding,  purging,  very  light  diet,  &c. — the  opposite 
of  a stimulatihg  or  tonic  treatment. 

Anus.  The  fundament;  the  circular  opening  at  the  lower  extremity  of  the 
rectum,  through  which  the  excrements  escape. 

Aplastic.  That  which  is  not  disposed  to,  or  is  incapable  of  becoming 
organized  or  vitalized. 

Apyrexia.  Absence  of  fever,  commonly  applied  to  the  period  between  the 
paroxysms  of  intermittent  fever. 


422 


GLOSSARY. 


Arachnitis.  Inflammation  of  the  arachnoid  membrane.  Synonymous  with 
phrensy,  or  brain  fever. 

Arachnoid  Membrane.  A thin,  serous  membrane,  resembling  a spider-web ; 
situate  between  the  pia  mater  and  dura  mater ; these  latter  mem- 
branes are  situated  in  the  interior  of  the  scull ; the  dura  mater  lining 
its  internal  cavity,  the  pia  mater  enveloping  the  brain,  and  both 
extending  into  the  spinal  canal,  enveloping  the  spinal  marrow. 

Articulo  mortis.  Dying. 

Ascites.  Dropsy  of  the  belly. 

Assimilation.  To  render  similar.  The  act  by  which  living  bodies  appro- 
priate and  transform  into  their  own  substance  matters  with  which 
they  may  be  placed  in  contact.  In  man,  assimilation  is  a function 
of  nutrition.  ( Dunglison .) 

Asodes.  Disgust,  nausea.  A variety  of  fever  attended  with  anxiety,  nau- 
sea, &c. 

Ataxia  or  Ataxic.  Applied  to  the  prostrated  condition  of  the  system  in 
cases  of  protracted  fever,  in  which  the  patient  is  very  feeble  and 
nervous. 

Auscultation.  The  act  of  listening.  Used  as  a means  of  diagnosis  in 
diseases  of  the  lungs,  heart,  &c.,  by  appreciating  the  different  ab- 
normal sounds,  or  their  variation  from  natural  or  healthy  ones. 

B. 

Biliary.  Pertaining  to  bile. 

Bilious.  Pertaining  to  bile,  or  that  which  is  produced  by,  or  contains  bile. 
A term  made  use  of  by  some,  applied  to  slight  derangement  of  health 
which  they  suppose  to  depend  on  torpidity  of  the  liver,  a deficiency 
of  bile,  or  a superabundance  of  secretion  of  bile,  or  biliary  derange- 
ment ; also  applied  in  the  same  way  to  diseases,  and  to  certain  con- 
stitutions in  which  there  is  supposed  to  be  a superabundance  of  the 
biliary  secretion ; as  in  the  bilious  temperament. 

Blaud’s  Ferruginous  Pills.  Take  of  Gum  Tragaeantli , in  powder,  six 
grains;  water,  one  drachm.  Macerate  in  a glass  or  porcelain  mortar, 
until  a thick  mucilage  is  formed  ; and  if  it  be  desired  to  prevent  the 
formation  of  peroxide  of  iron,  and  to  make  the  pills  similar  to  those 
of  Yallet,  substitute  a drachm  of  powdered  sugar  for  the  mucilage. 
Add  afterwards  of  sulphate  of  iron,  in  powder,  half  an  ounce.  Beat 
well  until  the  mixture  is  homogeneous,  and  add  subcarbonate  of  potass, 
half  an  ounce.  Beat  until  the  mass  becomes  of  a deep  green  color, 
and  of  a soft  consistence.  Divide  into  48  pills.  Dose,  one  a day ; 
gradually  increasing  to  two,  and  afterwards  to  three.  ( Dunglison .) 

Blood,  Composition  of  in  health.  In  1000  parts,  fibrin,  3 ; red  corpuscles 
or  globules,  127 ; water,  about  790;  solid  matter  of  the  serum,  80. 
According  to  M.  Lecanu,  the  blood  is  composed  in  1000  parts  of 
water,  785.590;  albumen,  69.415;  fibrin,  3.565;  coloring  matter, 


GLOSSARY. 


423 


119.626;  crystallizable  fatty  matter,  4.300;  oily  matter,  2.270;  ex- 
tractive matter  soluble  in  alcohol  and  -water,  1.920;  albumen  com- 
bined with  soda,  2.010 ; chlorides  of  sodium  and  potassium,  alkaline 
phosphates,  sulphates,  and  subcarbonates,  7.304;  subcarbonate  of 
lime  and  magnesia,  phosphate  of  lime,  magnesia  and  iron,  peroxide 
of  iron,  1.414 ; loss,  2.586. 

Blood-Globules.  Globules  of  the  blood,  Blood-corpuscles,  Blood-disks  or 
Blood-vesicles,  are  small,  circular  bodies,  which  constitute  a portion 
of  the  blood  of  all  animals.  “ The  globules  of  blood  are  circular  in 
the  mammalia,  and  elliptical  in  birds  and  cold-blooded  animals. 
They  are,  also,  flat  in  all  animals,  and  composed  of  a central  nucleus 
enclosed  in  a membranous  sac.”  ( Dunglison .) 

Borboryghus.  A dull  or  rumbling  noise  in  the  bowels,  produced  by  an 
accumulation  of  gas  or  wind. 

Bougie.  A round,  flexible  instrument,  of  different  sizes,  made  of  metal, 
gum  elastic,  &c. 

Bronchia.  The  two  tubes,  with  their  branches  or  ramifications,  which 
commence  at  the  lower  portion  or  bifurcation  of  the  windpipe. 

Bronchial-Respiration  or  Respiratory  Murmur.  The  noise  heard  during 
inspiration  and  expiration,  especially  the  former.  It  is  produced  by 
the  passage  of  the  air  through  the  bronchial  tubes,  and  into  the  air 
cells.  It  has  also  been  called  murmur  of  the  expansion  of  the  lungs  ; 
and,  when  distinctly  vesicular,  respiration  of  the  cells,  or  vesicular 
respiration.  Vesicular  respiration  is,  of  course,  absent  when  the 
cells  of  the  lungs  have  been  obliterated  from  any  cause. 

At  times,  it  is  rude  during  inspiration  or  expiration,  or  both — the 
Respiration  rude,  or  R.  rcipense  of  the  French.  At  others,  there  is  a 
blowing  sound  (French,  Souffle,  Respiration  soufflante),  as  if  some 
one  were  blowing  into  the  auscultator’s  ear  through  a tube.  This 
is  heard  in  the  healthy  state  over  the  larynx,  trachea,  and  about  the 
bifurcation  of  the  bronchia ; but  when  it  proceeds  from  the  lungs 
it  denotes  disease. 

The  respiration  perceived  over  the  trachea  and  bronchia  in 
health,  is  called  tracheal  or  bronchial,  or  tubal,  according  to  the 
situation  in  which  it  is  heard.  ( Dunglison .) 

Bronchitis.  Inflammation  of  the  lining  membrane  of  the  bronchia. 

Bronchophony,  or  Resonance.  A thrilling  of  the  voice  more  loud  than 
natural ; or  its  existence  in  a part  where  it  is  not  heard  in  health, 
as  detected  by  auscultation.  A thickened  and  hardened  state  of  the 
lungs,  caused  either  by  a mass  of  crude  tubercles,  or  by  inflamma- 
tion, is  generally  considered  to  produce  this  phenomenon,  by  render- 
ing the  lung  a better  conductor  of  the  murmur  of  the  voice  in  the 
bronchi. — Ibid. 

Bruit,  Sound.  A French  term,  applied  to  various  sounds  heard  on  per- 
cussion and  auscultation. 


424 


GLOSSARY. 


Bruit  de  Diable.  Noise  resembling  that  made  by  the  diable,  or  humming- 
top.  Venous  hum.  A high  degree  of  bruit  de  soufflet,  heard  on  aus- 
cultating the  arteries.  It  denotes  an  impoverished  state  of  the 
blood.  ( Dunglison .) 

Bruit  de  Scie,  or  “ saw  sound." 

Bruit  de  Soufflet.  Bruit  de  Souffle,  “bellows  sound,"  “blowing  sound." 
A sound  like  that  of  a bellows,  heard  occasionally  by  the  ear  applied 
to  the  chest  during  the  contraction  of  the  ventricles,  auricles,  or 
large  arteries.  It  co-exists  with  affections  of  the  heart ; but  is  heard, 
also,  without  any  disease  in  that  organ,  whenever,  indeed,  an  artery 
is  compressed. — lb. 


C. 

Cachectic.  Pertaining  to,  or  one  who  has  cachexia. 

Cachexia.  A bad  habit  or  condition  of  the  system,  in  which  it  is  depraved, 
debilitated,  and  in  which  the  red  corpuscles  are  more  or  less  below 
the  natural  standard,  127 ; as  in  chlorosis,  anemia,  hydropolycemia, 
dropsy,  scrofula,  consumption,  &c.,  which  see.  Cachectic  persons 
present  a pale,  tallo.wish,  or  exsanguious  appearance. 

Cacoplastic.  “ I form  bad."  That  which  is  scarcely,  or  only  in  a low 
degree,  susceptible  of  organization. 

Ceteris  Paribus.  All  other  things  being  equal. 

Capillary.  Prom  capillus.  A “ hair."  Small,  like  a hair. 

Capillary  Vessels.  The  extremely  small  vessels  at  the  ends  of  the  arte- 
ries and  veins,  which  connect,  or  form  a medium  of  communica- 
tion between  these  latter,  through  which  the  blood  passes  from  the 
former  to  the  latter.  In  the  capillary  system,  secretion  and  nutri- 
tion are  performed ; it  is  also  the  seat  of  inflammatory  and  other 
diseases. 

Capsicum.  Cayenne  pepper. 

Caput-CvECCm,  or  Caecum  Caput  coli.  The  blind  gut;  that  portion  of  the 
bowels  situated  between  the  lower  end  of  the  ileum,  or  small  gut, 
and  the  commencement  of  the  colon,  or  large  gut.  Its  length  is 
about  three  or  four  inches.  It  is  situated  in  the  right  iliac  fossa, 
between  the  lower  central  portion  of  the  abdomen  and  the  right  hip. 
The  appendix  vermiformis  cocci  is  attached  to  it. 

Cardiac.  Appertaining  to  the  heart,  or  upper  orifice  of  the  stomach. 

Carditis.  Inflammation  of  the  fleshy  substance  of  the  heart. 

Carotids.  The  large  arteries  or  blood-vessels  of  the  neck,  which  convey 
blood  to  the  head ; their  pulsations  may  be  felt  on  the  right  and  left 
of  the  windpipe,  or  larynx. 

Catamenia.  The  menses,  monthly  flow  of  females. 

Catamenial.  Pertaining  to  the  menses. 

Catarrhus  Vesicle.  Cystorrhoea,  Cystirrhcea.  An  affection  of  the  lining 
membrane  of  the  bladder,  which  gives  rise  to  a discharge  of  mucus 


GLOSSARY. 


425 


from  it,  which  passes  out  with  the  urine ; commonly  producing 
dysuria,  pain,  with  a sensation  of  heat  in  some  part  of  the  urethra, 
and  difficulty  in  passing  the  urine. 

Cava,  Vena.  The  two  great  veins  of  the  body,  which  meet  at  the  right 
auricle  of  the  heart.  The  inferior  one  arises  from  the  union  of  the 
two  primary  iliacs,  opposite  and  in  front  of  the  fourth  or  fifth  lumbar 
vertebra,  ascends  along  in  front  of  the  spine,  in  its  course  receiving 
several  veins,  and  opens,  as  above  stated,  at  the  posterior  and  infe- 
rior part  of  the  right  auricle  of  the  heart.  The  superior  one  is  formed 
by  the  union  of  the  subclavian  veins,  and,  like  the  inferior,  after  re- 
ceiving several  other  smaller  veins,  terminates  at  the  upper  part  of 
the  right  auricle  of  the  heart. 

Cavernous  Respiration.  When  a cavity  exists  in  the  lungs,  and  one  or 
more  ramifications  of  the  bronchia  terminate  in  it,  a loud  tubal  noise 
is  emitted,  provided  the  cavity  be  not  filled  with  fluid,  which  is  called 
cavernous  respiration.  In  this  condition,  the  cough  is  cavernous  like- 
wise. When  the  capacity  of  the  cavern  is  very  great,  the  sound  of 
respiration  is  like  that  produced  by  blowing  into  a decanter,  with 
the  mouth  at  a little  distance  from  the  neck.  This  kind  of  cavernous 
respiration  has  been  called  amphoric,  from  amphora,  “ a flask.” 
( Dunglison .) 

Cephalalgia.  Headache,  or  pain  in  the  head. 

Cephalitis.  Phrenitis,  inflammation  of  the  brain  or  its  membranes,  the 
latter  being  sometimes  called  Meningitis. 

Cerebral.  Appertaining  to,  or  similar  to  the  brain. 

Cerebro-spinal  Axis,  includes  the  brain  and  spinal  marrow.  The  au- 
thor has  occasionally  used  it  to  signify  the  medulla  oblongata,  or 
base  of  the  brain,  and  upper  portion  of  the  spinal  marrow ; as  when 
treating  of  typhoid  pneumonia,  or  spasmodic  croup. 

Chlorosis.  A disease  characterized  by  a pale  appearance,  debility,  &c., 
which  affects  young  females;  and  which  prevents,  or  otherwise  dis- 
turbs the  regular  and  healthful  appearance  of  the  menses.  (See 
Anemia.') 

Choleric.  Pertaining  to  cholera  morbus,  or  to  the  bile. 

Cholesterine.  An  insipid,  inodorous  substance  found  in  the  bile. 

Clavicle.  The  collar-bone,  one  end  of  which  is  in  contact  with  the  upper 
end  of  the  sternum,  or  breast  bone ; the  other  with  the  acromion  pro- 
cess of  the  scapula,  or  shoulder-blade. 

Collapse.  Great  prostration  of  strength,  which  is  more  likely  to  occur  in 
the  latter  stage  of  severe  or  malignant  diseases,  as  in  the  severer 
forms  of  remittent  fever ; but  in  some  other  diseases  the  stage  of 
collapse  may  come  on  early,  as  in  the  cold  stage  of  a severe  conges- 
tive chill,  or  cholera. 

Colliquative.  An  adjective  applied  to  copious  discharges  which  produce 
great  exhaustion  or  debility,  as  copious  liquid  evacuations  from  the 
bowels,  or  copious  sweating,  &c. 

28 


426 


GLOSSARY. 


Colon.  The  large  bowel,  which  extends  from  the  caecum  to  the  rectum. 

Coma.  A profound  or  deep  sleep,  from  which  it  is  more  or  less  difficult  to 
rouse  the  patient ; but  less  so  than  in  lethargy. 

Corrigent.  A medicine  given  to  prevent  any  unpleasant  or  unfavorable 
effect  of  the  principal  medicinal  agent,  as  compound  tincture  of  car- 
damoms, cinnamon,  paregoric,  or  the  like,  given  with  some  cathar- 
tics to  prevent  them  from  griping. 

Costalis.  Pertaining  to  the  ribs. 

Crepitant.  Crepitating.  Crackling. 

Crepitant  Kale.  Crepitant  Rattle, 'JaGurd  during  respiration,  in  severe 
pneumonia,  and  in  oedema  of  the  lung ; so  termed  on  account  of  the 
analogy  between  the  sound  and  that  occasioned  by  pressing  a healthy 
lung  between  the  fingers.  (Dunglison.) 

Crassamentum.  The  clot  of  the  blood. 

Cruor.  The  clot  of  the  blood,  or  crassamentum. 

Cystitis.  Inflammation  of  the  bladder.  Biliary  cystitis  is  inflammation  of 
the  gall-bladder. 

D. 

Decarbonization.  Hcematosis,  Arterialization  of  the  blood,  Atmospherization 
of  the  blood.  Venous  blood  contains  an  amount  of  carbonic  acid,  &c., 
which,  if  it  did  not  escape  from  the  system,  would  soon  accumulate 
to  such  an  extent  as  to  be  deleterious  or  poisonous ; hence,  when  it 
reaches  the  lungs,  this  superabundance  escapes  by  means  of  respi- 
ration ; oxygen,  from  the  air  breathed,  combines  with  the  venous 
blood — with  which  lymph  and  chyle  are  mixed  in  the  lungs — ren- 
dering it  more  florid,  and  better  suited  to  nourish  the  system,  in 
which  condition  it  is  called  arterial  blood. 

Decubitus.  Dying  down  in  a horizontal  posture. 

Diapedesis.  Exudation  of  blood  through  a membrane,  or  the  skin. 

Diaphoresis.  Perspiration. 

Diathesis.  This  word  is  applied  to  certain  conditions  or  affections  of  the 
system,  which  dispose  it  to  become  affected  with  certain  diseases 
rather  than  others.  Hence,  we  say  the  scrofulous  diathesis,  anemic 
or  chlorotic  diathesis,  gouty  diathesis,  cancerous  diathesis,  & c. 

Dorsal.  Relating  to  the  back,  or  one  of  its  parts.  The  dorsal  vertebrce  are 
the  twelve  bones  of  the  back  between  the  lower  portion  of  the  neek 
and  the  lumbar  vertebra,  the  latter  consisting  of  five  bones. 

Dorso-intercostal.  Relating  to  the  dorsal  region  and  between  the  ribs. 

Douche.  Dashing  or  pouring  water  on  the  body,  or  any  part  of  it. 

Duodenum.  A name  given  to  about  twelve  fingers’  breadth  of  the  intestine, 
extending  from  the  lower  orifice  of  the  stomach  to  that  portion  of 
small  intestine  called  the  jejunum. 

Dyspncea.  Difficult  breathing. 

Dysmenorrhcea.  Painful  menstruation. 

Dysuria.  Difficulty  of  passing  the  urine. 


GLOSSARY. 


427 


E. 

Elliptical  Plates.  Payer’s  glands , Agminated  glands.  Small  glands  or 
follicles,  situate  beneath,  the  villous  coat  of  the  intestines.  They  are 
clustered  together,  having  a honeycomb  appearance,  and  are  ex- 
tremely numerous.  They  occur  most  numerously  in  the  lower  por- 
tion of  the  ileum.  ( Dunglison .) 

Embonpoint.  “ In  good  point,  or  habit.”  The  state  or  condition  of  the  body 
when  it  presents  a, fleshy,  plump,  or  fat  appearance. 

Emesis.  Vomiting,  puking. 

Emphysema.  Wind-dropsy.  Applied  to  the  condition  of  a part  in  which 
air  has  escaped  into  the  cellular  substance. 

Emphysema  op  the  Lungs.  An  infiltration  of  air  into  the  cellular  texture 
of  the  lungs  ( interlobular  emphysema),  or  an  excessive  dilatation  of 
the  air  cells  ( vesicular  emphysema ). 

Emollients.  Substances  or  preparations  which  are  applied  to  relax  and 
soothe  parts  that  are  inflamed,  or  too  tense.  They  consist  of  cata- 
plasms or  poultices,  oils,  fomentations,  &c. 

Emulsion.  A milky-white,  opaque  preparation,  made  by  mixing  oil,  muci- 
lage, and  water. 

Encephaloid.  A name  given  to  certain  cancerous  or  scirrhous  tumors, 
in  which  their  substance  resembles,  in  appearance,  the  brain. 

Endermic.  The  application  or  method  of  applying  medicines  to  the  skin, 
especially  after  the  cuticle  has  been  removed. 

Endemico-Epidemic.  A compound  word,  applied  to  endemic  diseases  when 
they  manifest  an  epidemic  character. 

Enceinte.  One  with  child.  Pregnant. 

Enteritis.  Inflammation  of  the  intestines. 

Entomology.  The  science  or  natural  history  and  description  of  insects. 

Epialos.  A name  given  by  the  ancients  to  fever,  when  the  hot  stage  was 
mingled  with  irregular  chills.  Also,  the  cold  stage  of  fever.  ( Dun- 
glison.) 

Epigastric  Region,  Scrobiculus  cordis.  The  pit  of  the  stomach,  the  su- 
perior central  region  of  the  belly. 

Epigastrium.  The  epigastric  region.  Prcecordia. 

Epistaxis.  Bleeding  at  the  nose. 

Epithelial.  Pertaining  to  the  epithelium,  a thin  layer  of  epidermis,  skin 
or  membrane,  which  covers  the  interior  or  florid  portion  of  the  lips, 
the  nipple,  mucous  membranes,  &c. 

Exacerbation.  An  increase  in  the  violence  of  a disease;  the  hot  stage  of 
a fever.  A paroxysm. 

F. 

F.ecal,  Fecal.  Relating  to  the  faeces. 

FiECEs,  Feces.  The  excrements,  the  evacuations  from  the  bowels. 


428 


GLOSSARY. 


Femoral.  Pertaining  to  the  thigh. 

Fetor.  A had  smell.  Stench. 

Fibrin.  An  immediate,  solid,  white,  inodorous,  insipid  principle,  which 
constitutes  a portion  of  the  blood  and  chyle,  and  forms  the  chief  part 
of  the  flesh  of  red-blooded  animals. 

Follicle,  Crypta.  A crypt  or  follicle  is  a small,  roundish,  hollow  body, 
situate  in  the  substance  of  the  skin  or  mucous  membranes,  and  con- 
stantly pouring  the  fluid  which  it  secretes  on  their  surfaces. 

Fomites.  A word  applied  to  substances  which  are  supposed  to  retain  and 
convey  the  poison  which  propagates  contagious  diseases ; as  woollen 
or  cotton  goods,  &c. 

Fundus.  The  base  of  any  organ  which  ends  in  a neck,  or  has  an  external 
aperture ; as  the  fundus  or  upper  part  of  the  womb  or  bladder. 

Fungus,  plural,  Fungi.  A term  applied  by  botanists  to  a large  natural  order 
of  plants  of  a peculiar  organization  and  manner  of  growth,  compre- 
hending mushrooms,  toadstools,  the  microscopic  plants  which  form 
mold,  mildew,  smut,  &c.  The  word  is  also  applied  to  excrescences 
on  plants.  Also  proud  flesh.  Any  morbid  excrescence,  whether  in 
wounds,  or  arising  spontaneously. 

G. 

Gastric.  Pertaining  to  the  stomach. 

Gastritis.  Inflammation  of  the  stomach. 

Gastro-enteritis.  Inflammation  of  the  stomach  and  small  intestine,  or  of 
the  stomach  and  bowels. 

Glands  of  Brunner,  Solitary  Glands,  Solitary  Follicles.  Muciparous  fol- 
licles of  a small  size,  seated  between  the  mucous  and  muscular  coats 
of  the  stomach,  along  the  two  curvatures  of  that  organ,  and  in  the 
small  intestines,  especially  the  duodenum.  The  solitary  intestinal 
follicles  are  usually  known  at  the  present  day,  as  the  glands  of 
Brunner,  although  Brunner  restricted  the  latter  term  to  the  glands 
of  the  duodenum.  ( Dunglison .) 

H. 

H/Ematemesis.  Vomiting  of  blood. 

Hematosis.  (See  Decarbonization. ) 

Hemicrania.  Pain  confined  to  one-half  of  the  head. 

Hemoptysis.  Spitting  of  blood  (which  see,  in  the  work). 

Hemorrhage.  Bleeding.  Any  discharge  of  blood  from  vessels  destined  to 
carry  it,  with  or  without  rupture  of  their  coats  ; as  bleeding  from  the 
nose,  lungs,  &c. 

Hepatalgia.  Nervous  pain  of  the  liver  ; neuralgia  of  the  liver. 

Hepatic.  Pertaining  to,  or  resembling  the  liver. 

Hepatization.  Conversion  into  a liver-like  substance.  The  lungs  are 


GLOSSARY. 


429 


said  to  be  hepatized  when  they  are  engorged  with  effused  blood,  &c., 
are  impervious  to  air,  and  present  the  appearance  of  the  liver,  as 
sometimes  occurs  in  pneumonia. 

Humorism,  Humeral  Pathology . An  ancient  theory  which  referred  all  dis- 
eases to  the  morbid  condition  of  the  humors  or  jluid  parts  of  the 
body,  as  the  blood,  lymph,  &c. 

Hydrocele.  Dropsy  of  the  testicle,  or  scrotum. 

Hydropericarditis,  llydropericardium.  Dropsy  of  the  pericardium,  a 
membranous  sac  which  envelops  the  heart. 

IIydrothorax.  Dropsy  of  the  chest. 

Hygiene.  Health . Pertaining  to  the  preservation  of  health. 

IIyferjemia.  Preternatural  fullness  of  blood  in  a part,  or  preternatural 
accumulation  of  blood  in  the  capillary  vessels. 

Hypertrophy.  Morbid  enlargement  of  a part  with  increased  substance,  as 
enlargement  of  the  heart,  &c. 

Hypochondriac  Regions  are  two  in  number,  situated  to  the  right  and  left  of 
the  pit  of  the  stomach,  beneath  the  lateral  and  front  parts  of  the 
chest. 

I 

Ileon,  Ileum,  Ilium.  The  longest  portion  of  the  small  intestine,  which  ex- 
tends from  the  jejunum  to  the  caecum. 

Iliac.  Pertaining  to,  or  connected  with,  the  flanks. 

Iliac  Fossae.  The  hollow,  or  cavity,  formed  by  the  depression  on  the  in- 
ternal surface  of  the  hip-bone  (ilium).  This  term  is  also  applied  to 
a depression  on  the  external  surface  of  this  bone. 

Ilium,  Ilion,  Ilium,  Ileum.  The  hip  or  haunch  bone. 

Ingesta.  Substances  taken  into  the  stomach,  as  food,  &e. 

Innervation.  The  nervous  influence,  or  functions  of  the  nervous  system, 
which  are  necessary  for  the  maintenance  of  life  and  the  functions  of 
the  various  organs. 

Interscapular.  Between  the  scapula,  or  shoulder-blades. 

Isomeric.  An  epithet  applied  to  different  bodies,  which  agree  in  compo- 
sition, but  differ  in  properties.  This  condition  is  termed  Isomerism. 
( DungUson .) 

Isomorphous.  An  epithet  applied  to  different  bodies,  which  have  the  same 
crystalline  form.  The  condition  is  called  Isomorphism.— Ibid. 

Isopatiiia.  Parallelism  of  diseases.  The  disposition  of  diseases  to  anas- 
tomose with  each  other,  or  to  wear  each  other’s  livery. 

J. 

Jactitation,  Jactation.  Tossing  about.  Extreme  anxiety  ; excessive  rest- 
lessness. 

Jejunum.  That  portion  of  the  small  intestine  between  the  duodenum  and 
ileon. 


430 


GLOSSARY. 


L. 

Laryngitis.  Inflammation  of  the  larynx. 

Laryngotomy.  A surgical  operation,  which  consists  in  cutting  an  opening 
into  the  cavity  of  the  larynx,  for  the  purpose  of  extracting  some  fo- 
reign body,  or  to  remedy  an  obstruction  of  the  glottis.  Tracheotomy. 

Larynx.  A cartilaginous  cavity,  situated  at  the  upper  and  front  part  of 
the  neck,  at  the  upper  end  of  the  windpipe,  with  which  it  communi- 
cates. It  modulates  the  voice  in  speaking  and  singing. 

Lateritious.  Having  the  appearance  of  brick-dust. 

Leucophlegmatic.  Relating  to  a pale,  anemic,  or  dropsical  habit. 

Leucorrhcea,  Whites.  A disease  in  females,  attended  with  a more  or  less 
abundant  discharge  of  a white,  yellowish,  or  greenish  mucus,  from 
the  membrane  lining  the  genital  organs ; as  that  of  the  vagina  and 
womb. 

M. - 

Malaria.  Miasm. 

Malaise.  An  indescribable  feeling  of  being  unwell ; a feeling  of  indispo- 
sition. 

Mamma.  The  female  breast. 

Mammelonation,  Nammillated.  Small  mammiform  projections. 

Mastoid.  Having  the  form  of  a nipple.  The  mastoid  process  is  situated 
behind  and  below  the  ear,  at  the  inferior  and  posterior  part  of  the 
temporal  bone. 

Materia  Medica.  That  part  of  medical  science  which  treats  of  the  articles 
or  substances  used  in  the  practice  of  medicine,  their  action  on  the 
animal  economy,  and  mode  of  administration.  Also,  the  materials 
of  medicine. 

Medulla  Oblongata.  The  medullary,  or  nervous  substance,  that  lies  with- 
in the  cranium,  on  the  basilar  process  of  the  occipital  bone,  being  at 
the  base  of  the  brain,  and  connecting  it  with  the  spinal  marrow. 

Melanosis.  Black  tubercle,  Black  cancer.  An  organic  affection,  in  which 
the  tissue  of  the  parts  is  converted  into  black,  hard,  homogeneous 
substance,  near  which  ulcers  or  cavities  form — owing  to  the  soften- 
ing, either  of  this  substance  itself,  or  of  some  other  morbid  tissue — 
of  tubercles,  especially. 

Menorrhagia.  Profuse  menstruation.  Too  great  a flow  of  the  menses. 
Sometimes  used  synonymously  with  uterine  hemorrhage  or  metror- 
rhagia. 

Mesenteric  Glands  are  the  lymphatic  ganglions  of  the  mesentery.  Through 
them  the  chyliferous  vessels  pass  to  the  thoracic  duct.  When  they 
are  diseased,  nutrition  is  interfered  with,  and  marasmus,  or  a wasting 
away  of  the  body,  is  produced. 

Mesentery.  A membrane  in  the  cavity  of  the  abdomen,  attached  to  the 


GLOSSARY.' 


431 


lumbar  vertebras  posteriorly,  and  to  the  intestines  anteriorly.  It  is 
formed  of  a duplicature  of  the  peritoneum,  and  contains  adipose 
matter,  lacteals,  mesenteric  glands,  lymphatics,  and  mesenteric  arte- 
ries, veins,  and  nerves.  Its  use  is  to  retain  the  intestines  and  their 
appendages  in  a proper  position.  [Hooper.) 

Metastasis.  A mutation,  translation,  or  removal  of  a disease  or  morbid 
action  from  one  part  to  another. 

Meteorism,  Tympanites.  A swelling  of  the  abdomen,  caused  by  accumu- 
lation of  air  in  the  intestinal  tube,  or  in  the  peritoneum  (cavity  of 
the  abdomen). 

Metritis.  Inflammation  of  the  womb. 

Miasm.  A hypothetical  poison,  which  is  supposed  to  be  generated  in 
marshy  districts,  and  considered  to  be  the  cause  of  what  are  called 
malarious  diseases.  This  term  is  also  applied  to  poisonous  emana- 
tions from  the  bodies  of  the  sick,  or  from  animal  and  vegetable  sub- 
stances, or  from  the  earth. 

Miasmata.  (See  Miasm.) 

Miasmatic.  Pertaining  to  miasm. 

Moxa.  A substance  that  is  used  for  burning  the  skin;  a powerful  means 
of  counter-irritation. 

Mucous  Membranes  are  the  lining  membranes  of  the  cavities  which  have  an 
external  outlet,  as  of  the  bowels,  air-passages,  &c. 

Murmur,  Respiratory.  (See  Bronchial  Respiration.) 

N. 

Narcosis,  Narcotism,  Stupor,  Sleep.  The  condition  of  the  system  when 
under  the  stupefying  influence  of  opium  or  other  narcotics. 

Necroscopy.  Dissection,  Sectio-cadaveris,  Post-mortem  examination.  Atten- 
tive examination  of  the  body  after  death. 

Nervous.  Pertaining  to  the  nerves  or  nervous  system.  Also  weak,  irri- 
table. 

Neuralgia,  Nervous  pain.  Applied  to  nervous  diseases.  The  neuroses. 

Nosology.  A name  given  to  that  part  of  medicine  whose  object  is  the  clas- 
sification of  diseases.  Also,  Pathology.  ( Dunglison .) 

Nucha.  The  nape  of  the  neck. 

O. 

Omentum,  Epiploon.  The  caul. 

Organ.  Part  of  an  organized  being,  destined  to  exercise  some  particular 
function ; as,  for  instance,  the  stomach,  liver,  kidneys,  lungs,  &c. 

Organic  Nervous  System,  Ganglionic  Nervous  System.  That  part  of  the 
nervous  system  which  presides  over  nutrition  and  secretion.  It  is, 
however,  very  intimately  connected  with  the  spinal  and  cerebral 
divisions  of  the  nervous  system. 


432 


GLOSSARY. 


Orthopn(ea.  Impracticability  of  breathing,  except  in  the  erect  posture. 
Any  difficulty  of  breathing. 

Ovariotomy.  The  operation  of  cutting  out  an  ovary,  the  testicle  or  pride  of 
the  female. 

P. 

Papular.  Relating  to  papula,  pimples ; an  eruption  on  the  skin,  consist- 
ing of  small,  acuminated  elevations  of  the  cuticle,  with  an  inflamed 
base;  very  seldom  containing  a fluid,  or  suppurating,  and  commonly 
terminating  in  scurf. 

Parenchyma.  The  texture  of  glandular  and  other  organs,  composed  of 
agglomerated  globules  united  by  cellular  tissue,  and  tearing  with 
more  or  less  facility.  Such  is  the  texture  of  the  liver,  kidneys,  &c. 

( Dunglison .) 

Parietes,  Plural  of  Paries,  a wall.  A name  given  to  parts  which  form 
the  enclosures — the  limits  of  the  different  cavities  of  the  body.  Ibid. 

Pari  passu.  With  equal  pace,  or  progress.  Step  by  step. 

Pathognomonic.  A symptom,  or  symptoms,  characteristic  of  a disease ; 
the  symptoms  by  which  a disease  is  known  with  certainty. 

Pathology.  The  morbid  condition  which  constitutes  disease.  A discourse 
or  treatise  on  a disease,  or  diseases  in  general. 

Pectoriloquy,  Pedoriloquism,  Cavernous  voice.  Speech  or  voice  coming 
from  the  chest.  Laennec  has  designated,  by  this  name,  the  phe- 
nomenon often  presented  by  consumptive  individuals,  when  their 
chests  are  examined  with  the  stethoscope.  The  voice  seems  to  issue 
directly  from  the  chest,  and  to  pass  through  the  central  canal  of  the 
cylinder — a phenomenon  owing  to  the  voice  resounding  in  the  an- 
fractuous cavities,  produced  in  the  lungs  by  the  suppuration  or 
breaking  down  of  tubercles,  which  constitute  abscesses  or  ulcers  of 
the  lungs.  ( Dunglison .) 

Per  anum.  By  way  of,  or  through  the  anus. 

Percussion.  The  act  of  striking  the  external  walls  of  the  chest,  or  other 
parts,  so  as  to  elicit  or  produce  sound,  which  indicates  the  diseased 
or  healthy  condition  of  the  parts  beneath ; as  percussing  or  striking 
the  external  walls  of  the  chest,  in  order  to  ascertain  the  healthy  or 
diseased  condition  of  the  lungs,  heart,  &c. 

Pericardial  Sac.  The  pericardium. 

Pericarditis.  Inflammation  of  the  pericardium. 

Pericardium.  A membranous  sac  which  envelops  the  heart. 

Peritoneum.  The  serous  membrane  which  lines  the  cavity  of  the  abdomen, 
and  is  reflected  over  the  bowels,  &c. 

Peritonitis.  Inflammation  of  the  peritoneum. 

Perityphlitis.  Inflammation  of  the  cellular  substance  surrounding  the 
caecum. 

Petechia.  Small  spots  on  the  skin,  resembling  flea-bites. 


GLOSSARY. 


433 


Pharynx,  Fauces.  A symmetrical  canal,  on  the  median  line,  irregularly 
funnel-shaped,  situate  between  the  base  of  the  cranium  and  the  oeso- 
phagus, in  front  of  the  cervical  portion  of  the  spinal  column.  It  is 
very  narrow  above ; but  dilates  in  the  middle,  and  again  contracts 
below,  at  its  junction  with  the  oesophagus.  Into  the  anterior  walls 
of  the  pharynx  open,  successively,  from  above  to  below,  the  posterior 
orifices  of  the  nasal  fossae:  the  Eustachian  tubes;  the  posterior  aper- 
ture of  the  mouth,  and  the  top  of  the  larynx.  The  pharynx  gives 
passage  to  the  air  during  respiration,  and  to  the  food  at  the  time  of 
deglutition. 

Physical  Signs.  (See  page  109.) 

Pia  Mater.  A thin,  delicate  membrane,  which  covers  or  envelops  the 
brain  and  spinal  marrow  immediately. 

Pleura.  A serous  membrane,  one  of  which  lines  each  side  or  cavity  of 
the  chest.  That  portion  of  the  pleura  which  is  reflected  over  the 
lungs  is  called  Pleura  Pulmonalis;  and  that  which  lines  the  parietes 
or  internal  walls  of  the  chest,  Pleura  Costalis. 

Pneumonia,  Pneumonitis.  Inflammation  of  the  lungs ; vulgarly  called  lung 
fever. 

Pneumothorax.  An  accumulation  of  air  in  the  cavity  of  the  chest,  in  the 
cavity  formed  by  the  pleura. 

Post-mortem,  after  death.  A post-mortem  examination  of  a body,  is  one 
made  after  the  death  of  an  individual. 

Precordia  or  Precordial  Region.  The  epigastrium  or  epigastric  region  ; 
the  pit  of  the  stomach.  Also,  used  by  some  writers  for  the  region  of 
the  heart. 

Prodromic.  Prodromic  symptoms  are  the  first  symptoms  of  a disease ; the 
precursory  or  premonitory  symptoms. 

Profluvia.  Morbid  discharges  or  fluxes ; as  diarrhoea  or  dysentery. 

Prognosis.  The  judgment  or  prediction  formed  in  relation  to  the  future 
progress  and  termination  of  a disease. 

Prophylactic.  That  which  prevents  disease. 

Prophylaxis.  The  means  of  preventing  or  averting  disease. 

Pro  re  nata.  As  circumstances  or  occasion  requires. 

Pubis  or  Pubic  Region.  Pubes.  The  region  above  the  external  organs  of 
generation,  in  front  of  the  os  pubis,  at  the  lower  part  of  the  abdomen, 
and  which  is  covered  with  hair  in  both  sexes  at  the  age  of  puberty. 

Pylorus.  The  orifice  at  the  lower  portion  of  the  stomach,  through  which 
food  passes  into  the  bowels. 

Pyrexia.  Fever. 


Q- 


Quartan.  A type  of  ague,  the  paroxysm  of  which  recurs  every  third  day, 
or  with  intermissions  of  seventy-two  hours. 


434 


GLOSSARY. 


Quininism.  The  aggregate  effects  produced  on  the  brain  and  nervous  sys- 
tem by  too  much,  or  the  improper  exhibition,  of  quinine. 

Quintan.  An  intermittent  fever,  the  paroxysms  of  which  return  every 
fifth  day ; with  three  intervening  days  without  fever. 

Quotidian.  A type  of  ague  and  fever,  the  paroxysm  of  which  returns 
every  day,  or  every  twenty-four  hours. 

It. 

Rale.  Rattle. 

Rattle.  Bhonchus.  A term  that  has  been  given  to  different  sounds  during 
respiration,  caused  by  the  air  passing  through  fluid  contained  in  the 
bronchi,  or  areolae  of  the  pulmonary  tissue ; which  are  perceived  by 
auscultation. 

Also,  noise  produced  by  the  air  in  passing  through  mucus,  of 
which  the  lungs  are  unable  to  free  themselves.  This  condition  is 
chiefly  observed  at  the  approach  of  death,  and  is  commonly  called, 
“ The  Battles.”  ( Dunglison .) 

Rhonchus,  Mucous.  Mucous  rattle.  Subcrepitant  rhonchus.  The  sound 
produced  by  the  passage  of  air  through  mucus  accumulated  in  the 
bronchi  or  trachea,  or  through  softened  tubercular  matter.  This 
rale  occurs  in  catarrh,  and  in  softened  tubercle.  When  carried  to 
a very  high  degree,  it  constitutes  gurgling.  ( lb .) 

Rhonchus,  Sibilant.  Sibilant  rattle,  Bale  sibilant.  A slight,  though  pro- 
longed whistling  sound ; occurring  either  at  the  commencement  of 
inspiration,  or  of  expiration ; owing  to  the  presence  of  mucus,  thin 
and  viscid,  but  not  abundant ; which  obstructs,  more  or  less  com- 
pletely, the  smaller  bronchial  ramifications.  It  is  seated  in  the 
small  tubes,  and  occurs  in  the  first  stage  of  bronchitis.  (16.) 

Rhonchus,  Sonorous.  Sonorous  rattle.  A sound  resembling,  at  times,  the 
snoring  of  a person  asleep  ; at  others,  the  sound  of  the  bass  string 
of  an  instrument  when  rubbed  with  the  finger,  and  not  unfrequentlv 
the  cooing  of  a dove.  It  seems  to  be  caused  by  a contraction  of  the 
bronchial  tubes,  and  is  characteristic  of  chronic  catarrh.  (16.) 

Recipe.  R.  Take.  Placed  at  the  top  or  commencement  of  a formula  or 
prescription. 

Rectum.  That  portion  of  the  large  bowel  situated  immediately  above  the 
anus,  and  below  the  sigmoid  flexure  of  the  colon.  It  is  vulgarly 
called  “ The  Arse-gut.” 

S. 

Sacrum,  Os  sacrum.  The  bone  at  the  back  part  of  the  pelvis,  below  the 
loins,  and  on  the  upper  part  of  which  the  lower  lumbar  vertebra 
rests. 

Sanguinaria  Canadensis.  Puccoon,  or  blood-root. 

Sanious,  Ichorous.  Relating  to  ichor  or  sanies,  a thin,  acrid,  irritating  dis- 


GLOSSARY. 


435 


charge,  -which  comes  from  the  surface  of  foul  ulcers,  or  those  which 
are  not  inclined  to  heal  readily. 

Sarcocele.  A fleshy  tumor  of  the  testicle. 

Scapula.  The  shoulder-blade. 

Scirrhus.  A hard  or  indurated  tumor,  commonly  attended  by  shooting 
pains,  and  considered  to  be  of  a cancerous  nature. 

Scrofula.  A species  of  anemia,  in  which  indolent  glandular  tumors  occur, 
principally  about  the  neck,  and  in  the  mesentery,  affecting  the  mesen- 
teric glands,  in  which  latter  case  it  is  called  Tabes  mesenterica.  The 
glandular  swellings  frequently  result  in  ulceration,  which  heals  with 
difficulty.  Scrofula  may  also  terminate  in  consumption. 

Scrofulosis,  Scrofula,  Scrophula. 

Scrofulous.  Relating  to,  or  suffering  from  scrofula. 

Sectio  Cadaveris.  (See  Post-mortem.) 

Serous  Poly.emia,  Hydro-poly  cemia.  Too  much  water  in  the  blood.  Like 
the  other  species  of  anemia,  it  is  attended  with  a diminution  in  the 
amount  of  the  blood-globules. 

Sextan.  Applied  to  an  ague  which  returns  every  sixth  day. 

Sigmoid  Flexure  of  the  Colon.  A crooked  portion  of  the  colon,  resem- 
bling the  letter  S,  which  is  situated  in  the  left  lower  portion  of  the 
abdomen,  and  communicates  with  the  rectum. 

Sinapism.  A cataplasm,  of  which  mustard  is  the  basis ; commonly  made 
by  mixing  mustard,  flour,  and  vinegar  or  water,  together. 

Singultus.  Hiccough. 

Sinus.  This  word  is  applied  to  certain  cavities,  as  in  the  bones  of  the  face 
and  head,  in  which  the  interior  is  more  expanded  than  the  entrance. 
It  is  also  applied  to  certain  venous  canals  into  which  a number  of 
vessels  empty. 

Solitary  Glands.  (See  Glands  of  Brunner.) 

Speculum.  A hollow  instrument,  used  for  the  purpose  of  dilating  a cavity, 
so  that  the  condition  of  the  parts  within  may  be  seen ; as  its  intro- 
duction into  the  vagina,  to  observe  a diseased  condition  of  the  neck 
or  mouth  of  the  womb. 

Sphacelus.  The  disorganized  or  dead  portion  of  an  ulcer,  which  separates 
or  sloughs  off  from  the  living  tissue  by  means  of  mortification  or 
gangrene.  Also  gangrene,  mortification,  or  slough. 

Sphincter  Ani.  A muscle  which  surrounds  and  closes  the  anus,  the  open- 
ing through  its  centre  constituting  the  latter. 

Spinal.  Pertaining  to  the  spine ; as, 

Spinal  Irritation.  An  affection  of  the  spinal  marrow  or  nerves;  which 
see  described  in  the  work. 

Splenitis.  Inflammation  of  the  spleen. 

Splenotomy.  The  operation  of  cutting  out  the  spleen. 

Sporadic.  Diseases  are  said  to  be  sporadic  which  occur  at  any  time,  and 
are  not  epidemic,  endemic,  or  contagious. 

Sporule,  Spore.  “I  sow.”  The  reproductive  body  in  cryptogamous  plants, 


436 


GLOSSARY. 


which  is  analogous  to  the  seed  of  phanerogamous  plants.  ( Dun - 
glison.) 

Sputa.  Plural  of  Sputum,  Spit. 

Sternal.  Relating  or  pertaining  to  the 

Sternum.  The  breast-bone. 

Stomachic.  Stomachal.  A corroborant  or  medicine  which  strengthens  or 
gives  tone  to  the  stomach. 

Styptic.  A medicine  possessed  of  constringent  properties,  and  which  is 
applied  locally,  to  arrest  bleeding  or  too  copious  discharges.  Also, 
used  synonymously  with  astringent. 

Subsultus  Tendinum.  Twitching  of  the  tendons,  caused  by  the  involuntary 
and  instantaneous  contractions  of  the  muscular  fibres,  most  com- 
monly observed  at  the  wrist,  but  occurring  also  elsewhere. 

Sui  generis.  This  term  is  applied  to  anything  that  is  peculiar  to  itself. 

Syphilis.  Lues  venerea,  Pox,  French  Pox. 

T. 

Tabes  Mesenterica.  Scrofula  mesenterica,  Mesenteric  Disease.  (See 
Scrofula.) 

Tannin.  Tannic  acid  is  an  astringent  principle  contained  in  oak  bark  and 
other  vegetable  astringents,  from  which  it  may  be  extracted.  It  is 
called  Tannin,  from  its  being  the  principal  agent  in  the  process  of 
tanning. 

Taraxacum.  Dandelion. 

Temperament.  This  term  is  used  to  designate  the  peculiar  constitutions  of 
different  persons,  in  consequence  of  the  variety  of  relations  and  pro- 
portions between  the  constituent  parts  of  the  body  ; hence,  when  an 
individual  appears  stout,  and  presents  a florid  appearance,  we  say 
he  is  of  a Sanguine  Temperament ; if  he  is  somewhat  pallid  and  plump, 
possessing  a good  degree  of  embonpoint,  his  temperament  is  said  to 
be  lymphatic ; if  he  is  still  more  pallid,  we  say  he,  or  she,  as  the  case 
may  be,  is  of  a Phlegmatic  or  Leucophlegmatic  appearance  or  tem- 
perament, in  which  there  is  a greater  or  less  degree  of  anemia.  The 
Bilious  Temperament  is  applied  to  those  who  present  a rather  dark, 
lean  appearance,  and  who  have  dark  hair.  Those  who  possess  a 
Nervous  Temperament  are  commonly  excitable,  nervous,  quick,  and 
usually  have  a slender  form.  In  most  persons,  however,  there  is  a 
mixture  of  temperaments  ; hence,  we  say  sanguineo-nervous,  lympha- 
tico-nervous,  bilio-sanguineous  temperament,  & c. 

Tenesmus.  Frequent  and  painful  desires  to  go  to  stool,  attended  with  very 
little  or  no  discharges. 

Tertian.  Tertian  ague.  An  ague  whose  paroxysms  return  every  other 
day,  or  every  48  hours. 

Thoracic.  Appertaining  to  the  thorax,  or  chest. 


GLOSSARY. 


437 


Thorax.  Chest,  Breast.  The  lungs  and  heart  are  situated  within  the 
thorax. 

Tinnitus  Aurium.  Ringing  of  the  ears. 

Tormina.  Griping  pains  in  the  bowels,  as  in  dysentery. 

Trachea.  The  windpipe. 

Tracheal.  Trachealis.  An  epithet  applied  to  the  respiration  as  heard 
through  the  stethoscope,  opposite  the  trachea,  larynx,  and  root  of  the 
bronchia  ; the  air  appearing  as  if  sucked  in  from  the  cylinder  during 
inspiration,  and  expelled  during  expiration.  (Dunglison.) 

Tracheitis.  Inflammation  of  the  lining  membrane  of  the  trachea.  Cy- 
nanche  trachealis.  (See  Croup.) 

Tracheotomy.  (See  Laryngotomy.) 

Tubercle.  (See  page  102.) 

Tuberculosis.  Tubercular  cachexia,  as  consumption,  &c. 

Tuberculous.  Tubercular.  Relating  to  tubercular  disease. 

Tympanites.  (See  Meteorism.) 

Typhlitis.  Inflammation  of  the  caecum. 

Typhus  Grayior.  A severe  form  of  typhus  fever. 

U. 

Utero-gestation.  Pregnancy. 

V. 

Yagina.  “ A sheath.”  The  vulvo-uterine  canal,  which  is  cylindrical  and  four 
or  six  inches  long  in  the  adult;  situated  between  the  rectum  and  blad- 
der, communicating  at  its  external  end  with  the  os  externum  or  ex- 
ternal organs  of  generation,  in  the  female,  and  at  the  other,  at  the 
uterus,  the  neck  of  which  it  embraces.  The  male  organ  enters  this 
cavity  in  copulation ; and  through  it  the  secretions  and  contents  of 
the  womb  are  permitted  to  escape  externally. 

Vallet’s  Ferruginous  Pills.  Pills  of  Carbonate  of  Iron.  These  pills  are 
made  as  follows  : Take  of  sulphate  of  iron,  four  ounces;  carbonate 
of  soda,  five  ounces ; clarified  honey,  two  ounces  and  a half;  syrup, 
boiling  water,  each,  a sufficient  quantity.  Dissolve  the  sulphate  of 
iron  and  carbonate  of  soda,  each,  in  a pint  of  the  water,  and  to  each  so- 
lution add  a fluidounce  of  syrup ; then  mix  the  two  solutions  in  a 
bottle  just  large  enough  to  contain  them,  close  it  accurately  with  a 
stopper,  and  set  it  by  that  the  carbonate  of  iron  may  subside.  Pour 
off  the  supernatant  liquid,  and,  having  washed  the  precipitate  with 
warm  water,  sweetened  with  syrup  in  the  proportion  of  a fluidounce 
of  the  latter  to  a pint  of  the  former,  until  the  washings  no  longer 
have  a saline  taste,  place  it  upon  a flannel  cloth,  and  express  as 
much  of  the  water  as  possible ; then  immediately  mix  it  with  the 


438 


GLOSSARY. 


honey.  Lastly,  heat  the  mixture,  by  means  of  a water-bath,  until 
it  attains  a pilular  consistence.  U.  S.  Disp. 

When  the  above  is  made  into  pills,  each  one  should  weigh  from 
three  to  five  grains,  one  of  which  may  be  taken  three  or  four  times 
a day.  Dr.  Bache  says,  “ There  can  be  but  little  doubt  that,  in 
cases  in  which  the  alterative  effects  of  iron  are  called  for,  Tallet’s 
preparation  is  superior  to  any  other  derived  from  that  metal." 

Vena  Azygos.  Azygos  vein.  This  vein  forms  a communication  between 
the  Vena  cava  inferior  and  Vena  cava  superior,  permitting  the  blood 
to  pass  freely  between  the  two. 

Vena  Cava.  (See  Cava  Vena.) 

Venous.  Pertaining  to  a vein. 

Ventricle.  A “ Little  Belly.'”  A name  given  to  several  parts  ; as, 

Ventricles  of  the  Heart.  Two  cavities  in  the  anterior  part  of  the  heart, 
one  on  each  side,  into  which  the  venous  blood  passes  from  the  auri- 
cles or  ears  of  the  heart,  and  from  thence  into  the  arteries,  the  right 
ventricle  communicating  with  the  pulmonary  artery ; and  the  left 
ventricle  with  the  aorta,  the  largest  artery  or  blood-vessel  of  the 
body,  which  distributes  blood  to  nearly  all  of  it. 

Verba  magistri.  Merely  the  words  of  a tutor  or  teacher. 

Vertebrae.  The  bones  which,  by  their  union,  form  the  vertebral  or  spinal 
column,  vulgarly  called  the  back-bone.  The  vertebrae  are  twenty-four 
in  number;  namely,  seven  in  the  neck,  called  the  cervical  vertebrae; 
the  next  twelve  below  are  called  the  dorsal  vertebrae;  and  the  five 
lower  ones  the  lumbar  vertebrae. 

Villous  Membranes  or  Coats,  are  such  as  are  covered  with  soft  papillae,  or 
villi,  constituted  of  blood-vessels,  nerves,  and  absorbents.  Chaus- 
sier  gives  the  name  simple  villous  membranes  to  the  serous  mem- 
branes ; and  that  of  complicated  or  follicular  villous  membranes  to  the 
mucous  membranes.  ( Dunglison .) 

Viscera.  Plural  of  Viscus.  The  organs  contained  within  the  three  great 
cavities  of  the  body — the  abdomen,  chest,  and  head ; as  the  entrails, 
liver,  lungs,  heart,  brain,  &c. 

Visceral.  Pertaining  to  the  viscera. 

Viscus.  (See  Viscera.) 


In  preparing  the  above  Glossary,  I frequently  referred  to  Dunglison’s 
Medical  Dictionary,  sometimes  adopting  his  definitions,  in  part. 


9, 


INDEX. 


A 

Achillea  millefolium,  179 
Ague  and  fever,  30 
Appendix,  399 
Atonic  dyspepsia,  162 

B 

Bad  cold,  416 
Bark,  Peruvian,  178 
willow,  178 
Bilious  fever,  224 
Blood  in  consumption,  96 — 98 
Blood  globules  in  cachexia,  87 
Boneset,  179 
Bronchitis,  chronic,  143 
treatment,  144 

C 

Cachexia,  80 
anemia,  80 
blood-globules  in,  87 
chlorosis,  86 — 88 
treatment,  121 
consumption,  &c.,  94 
pathology,  114 
blood  in,  96 — 98 
treatment,  125 
diet  in,  137 
dyspepsia,  atonic,  162 
hydropolysemia,  80 — 83 
rickets,  139 
scrofula,  139 
scrofulous  matter,  106 
serous  polysemia,  80 — 83 
splenic,  152 
tabes  mesenterica,  143 
treatment,  121 
tuberculous,  &c.,  94 
causes,  98 


Cachexia,  tuberculous 

pathology,  114 
white  swelling,  95 
tubercle,  102 

microscopic  appearances, 
102 

composition,  105 
Catarrh,  or  cold,  416 
Cherry-tree  bark,  179 
Chills  and  fever,  30 
Chiniodine,  177 
Cholera,  Asiatic,  353 
causes,  359 
history,  354 

means  of  prevention,  371 
pathology,  364 
remarks,  380 
symptoms,  365 
treatment,  375 

of  cholerine,  373 
Clap,  399 
Cold,  416 

Collodion,  410—412 
Congestive  chills,  180 
fever,  180 

Concussion,  or  fall,  407 
Contused  wounds,  409 
Convulsions,  puerperal,  160 
Cornus  cericea,  179 
Cornus  Florida,  179 
Cotton,  gun,  410 
Croup,  383 

Cynanche  trachealis,.383 

D 

Diarrhoea  and  dysentery,  326 
causes,  327 — 331 
pathology,  333 
treatment,  340 
chronic,  treatment,  345,  352 
diet  in,  352 


440 


INDEX, 


Diseases,  malarious,  periodicity  of,  49 
Dislocation  of  the  spleen,  54 
Dogwood,  179 
'swamp,  179 
Dropsy,  treatment,  150 
Dysentery  and  Diarrhoea,  326 
Dysmenorrhcea,  172 
Dyspepsia,  162 


E 

Enlargement  of  the  spleen,  152 
liver,  155 

Ephemeral  fever,  418 
Epilepsy,  160 

Eupatorium  perfoliatum,  179 


F 

Falling  down  of  the  womb,  170 
Ferrocyanate  of  quinia,  176 
Fever,  bilious,  224 
congestive,  180 

algide  variety,  186 
choleric  variety,  15,  18,  185 
with  coma  and  costiveness, 
184 

embonpoint,  187 
duration,  202 
pathology,  196 
prognosis,  203 
terminations,  191 
treatment,  205 
intermittent,  30 
and  ague,  30 

anomalous  varieties,  42,  43 
causes,  30 
chills  and,  30 
cold  stage,  37 
hot  stage,  41 
sweating  stage,  44 
pathology,  47 
prodromic  form,  35 
treatment,  36 
post-mortem,  62 
blood  in,  63 
prognosis,  61 
prophylaxis,  66 
terminations,  52 
types  of,  45 
treatment,  67 

premonitory  stage,  67 
cold  stage,  68 
hot  stage,  70 
sweating  stage,  71 


Fever,  chills  and,  treatment  of  chronic 
form,  74 
ephemeral,  418 
remittent,  224 
causes,  225 
forms  of 

1.  Mild  form,  228 

2.  Causus,  230 

3.  Comatose,  or  nervous,  234 

4.  Typhoid,  236 
pathology,  242 
prognosis,  240 
treatment,  259 

1.  Mild  form,  259 

2.  Causus,  261 

3.  Comatose,  281 

4.  Typhoid,  285 
diet  in,  288 
convalescence,  289 

yellow,  294 

treatment,  299 
Fevers,  malarious,  9 

periodicity,  49 

Fits,  160 

G 

Gentian,  179 
Glossary,  421 
Gonorrhoea,  399 
Green  sickness,  86 — 88 
treatment,  121 
Gun  cotton,  410 

II 

Haemoptysis,  147 
Holly,  179 
Horehound,  179 
Ilydropolyaemia,  80,  88 
treatment,  150 

I 

Incised  wounds,  408 
Intermittent  fever,  30 
Inflammation,  chronic,  of  womb,  170 
Itch,  420 

J 

Janders,  yellow,  293 
Jaundice,  293 

L 

Lacerated  wounds,  409 


INDEX. 


441 


Leucorrhcea,  165 
treatment,  167 

Sulphate  of  iron  (copperas),  179 
Sulphur,  179 

M. 

T 

Malarious  fevers,  9 
Marubium  vulgare,  179 
Menstruation,  painful,  172 
Metritis,  chronic,  170 
Miscellaneous,  407 

Tabes  mesenterica,  143 
Thoracic  vibration,  112 
Tubercle,  102 

composition  of,  105 
microscopic  appearance  of,  102 
Tuberculous  cachexia,  94 

N 

Tuberculosis,  pathology  of,  114 
Typhoid  pneumonia,  308 
description,  311 
1st  form  of  attack,  311 

Nervous  diseases,  156 
treatment,  157 

2d  form  of  attack,  312 
duration,  314 
causes,  314 

P 

pathology,  315 
physical  signs,  316 
treatment,  316 

Peruvian  bark,  178 
Physical  signs,  109 
Poplar  bark,  179 
Prolapsus  uteri,  170 
Prussian  blue,  179 
Puerperal  convulsions,  160 

U 

Uterus,  prolapsus  of,  170 

chronic  inflammation,  170 
falling  of,  170 

Q 

V 

Quinia,  ferrocyanate  of,  176 
Quinine,  endermic  use  of,  176 

Vibration,  thoracic,  112 

R 

W 

Remittent  fever,  224 
Rheumatism,  acute,  306 
chronic,  140 
Rickets,  95,  139 

Whites,  165 
White  swelling,  95 
Willow  bark,  178 
Womb  (see  Uterus),  170 
Worms,  413 

S 

Wounds,  contused,  409 
incised,  408 

Salicin,  179 
Scabies,  420 
Scrofula,  139 
Serous  polysemia,  80 — 83 
treatment,  150 
Spleen,  dislocation  of,  54 
Splenic  cachexia,  152 
Spitting  of  blood,  147 
Strychnine,  178 

lacerated,  409 
Y 

Yarrow,  179 
Yellow  fever,  294 
treatment,  299 
Yellow  janders,  293 

THE  END. 


29 


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